Provider Demographics
NPI:1619244035
Name:RACICH, DOUGLAS JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:JAMES
Last Name:RACICH
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 1:6411 N OVERLOOK RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49670-9437
Mailing Address - Country:US
Mailing Address - Phone:231-499-2927
Mailing Address - Fax:
Practice Address - Street 1:6411 N OVERLOOK RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:MI
Practice Address - Zip Code:49670-9437
Practice Address - Country:US
Practice Address - Phone:231-499-2927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017290122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist