Provider Demographics
NPI:1508077082
Name:DOUGAN, GARY LEE (DDS, MPH)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:DOUGAN
Suffix:
Gender:M
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 CAPTAINS CV
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-2311
Mailing Address - Country:US
Mailing Address - Phone:510-841-4568
Mailing Address - Fax:
Practice Address - Street 1:17 CAPTAINS CV
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-2311
Practice Address - Country:US
Practice Address - Phone:510-841-4568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29257122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist