Provider Demographics
NPI:1841213915
Name:FLORENCE, DOUGLAS ANDREW (DDS)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ANDREW
Last Name:FLORENCE
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 1:417 GRAND PARK DR STE 109
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26105-4049
Mailing Address - Country:US
Mailing Address - Phone:304-422-4455
Mailing Address - Fax:
Practice Address - Street 1:417 GRAND PARK DR STE 109
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26105-4049
Practice Address - Country:US
Practice Address - Phone:304-422-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV34501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7800026000Medicaid