Provider Demographics
NPI:1801010699
Name:DOUGLASS, GORDON LADD (DDS)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:LADD
Last Name:DOUGLASS
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 1:3960 EL CAMINO AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-6534
Mailing Address - Country:US
Mailing Address - Phone:916-483-4964
Mailing Address - Fax:916-483-6380
Practice Address - Street 1:3960 EL CAMINO AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-6534
Practice Address - Country:US
Practice Address - Phone:916-483-4964
Practice Address - Fax:916-483-6380
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA217921223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics