Provider Demographics
NPI:1992701643
Name:TRAUB, DOUGLAS S JR (DMD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:S
Last Name:TRAUB
Suffix:JR
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 1:610 E WAKEFIELD BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTED
Mailing Address - State:CT
Mailing Address - Zip Code:06098-2914
Mailing Address - Country:US
Mailing Address - Phone:860-379-4151
Mailing Address - Fax:
Practice Address - Street 1:454 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-4937
Practice Address - Country:US
Practice Address - Phone:860-482-8750
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0054141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTDO 5414 SUFFIX TRMedicaid