Provider Demographics
NPI:1598481228
Name:DOUGLAS DENTAL CORPORATION
Entity Type:Organization
Organization Name:DOUGLAS DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:CHELSEY
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-616-7817
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:303-952-0892
Practice Address - Street 1:10930 MAGNOLIA BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-3903
Practice Address - Country:US
Practice Address - Phone:818-616-7817
Practice Address - Fax:818-638-9608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty