Provider Demographics
NPI:1922142249
Name:KELLOGG, DOUGLAS ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:ALAN
Last Name:KELLOGG
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 1:2733 HORSE PEN CREEK RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-8399
Mailing Address - Country:US
Mailing Address - Phone:336-854-9270
Mailing Address - Fax:336-854-5628
Practice Address - Street 1:2733 HORSE PEN CREEK RD
Practice Address - Street 2:SUITE 107
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-8399
Practice Address - Country:US
Practice Address - Phone:336-854-9270
Practice Address - Fax:336-854-5628
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC53071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5307OtherDENTAL LICENSE