Provider Demographics
NPI:1932315884
Name:DOUGLAS, DALE STEPHEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:STEPHEN
Last Name:DOUGLAS
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 1:304 E RAND RD STE 260
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-3190
Mailing Address - Country:US
Mailing Address - Phone:847-670-7099
Mailing Address - Fax:
Practice Address - Street 1:304 E RAND RD STE 260
Practice Address - Street 2:
Practice Address - City:ARLINGTON HTS
Practice Address - State:IL
Practice Address - Zip Code:60004-3190
Practice Address - Country:US
Practice Address - Phone:847-670-7099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist