Provider Demographics
NPI:1982858247
Name:DOUGLAS, PHILLIP R (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:R
Last Name:DOUGLAS
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 1:4850 KEYSTONE XING
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-5076
Mailing Address - Country:US
Mailing Address - Phone:715-855-1020
Mailing Address - Fax:
Practice Address - Street 1:4850 KEYSTONE XING
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-5076
Practice Address - Country:US
Practice Address - Phone:715-855-1020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-12
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011180A122300000X
WI6330122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist