Provider Demographics
NPI:1801358395
Name:DOUGLAS DENTISTRY P A
Entity Type:Organization
Organization Name:DOUGLAS DENTISTRY P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:727-372-3200
Mailing Address - Street 1:1821 WELLNESS LN BLDG 3
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-5359
Mailing Address - Country:US
Mailing Address - Phone:727-372-3200
Mailing Address - Fax:
Practice Address - Street 1:1821 WELLNESS LN BLDG 3
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-5359
Practice Address - Country:US
Practice Address - Phone:727-372-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOUGLAS DENTISTRY P A
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-03
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies