Provider Demographics
NPI:1992852818
Name:CHURCH, DOUGLAS CHADWICK (DDS)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:CHADWICK
Last Name:CHURCH
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 1:6000 FAIRWAY DR STE 15
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-4246
Mailing Address - Country:US
Mailing Address - Phone:916-632-3650
Mailing Address - Fax:
Practice Address - Street 1:6000 FAIRWAY DR STE 15
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-4246
Practice Address - Country:US
Practice Address - Phone:916-632-3650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA544791223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics