Provider Demographics
NPI:1659437580
Name:CALLIS, DOUGLAS STEVEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:STEVEN
Last Name:CALLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 OLD TOLL RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-1836
Mailing Address - Country:US
Mailing Address - Phone:203-421-4100
Mailing Address - Fax:203-421-4159
Practice Address - Street 1:515 OLD TOLL RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-1836
Practice Address - Country:US
Practice Address - Phone:203-421-4100
Practice Address - Fax:203-421-4159
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7791122300000X
CTCT77911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT020007791CTMedicaid