Provider Demographics
NPI:1578785473
Name:MASSINGILL, DOUGLAS LEWIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:LEWIS
Last Name:MASSINGILL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 OVEROAKS PL
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-7118
Mailing Address - Country:US
Mailing Address - Phone:407-328-9421
Mailing Address - Fax:
Practice Address - Street 1:1300 RED JOHN DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32124-1075
Practice Address - Country:US
Practice Address - Phone:386-254-1547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 92761223G0001X
GADN0106971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice