Provider Demographics
NPI:1679648349
Name:VETSCH, DOUGLAS MATTHEW
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:MATTHEW
Last Name:VETSCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DOUGLAS
Other - Middle Name:M
Other - Last Name:VETSCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:114 NE JACKSON
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526
Mailing Address - Country:US
Mailing Address - Phone:541-476-7725
Mailing Address - Fax:541-479-5950
Practice Address - Street 1:114 NE JACKSON
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526
Practice Address - Country:US
Practice Address - Phone:541-476-7725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4786122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist