Provider Demographics
NPI:1790963957
Name:PEARSON, DOUGLAS L (DMD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:L
Last Name:PEARSON
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 1:2225 NORMAN LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-3357
Mailing Address - Country:US
Mailing Address - Phone:719-564-3199
Mailing Address - Fax:719-564-6302
Practice Address - Street 1:2225 NORMAN LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-3357
Practice Address - Country:US
Practice Address - Phone:719-267-5078
Practice Address - Fax:719-267-5079
Is Sole Proprietor?:No
Enumeration Date:2008-02-09
Last Update Date:2008-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COH-D-1-006191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice