Provider Demographics
NPI:1184794992
Name:HEAD, DOUGLAS W (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:W
Last Name:HEAD
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-4437
Mailing Address - Country:US
Mailing Address - Phone:630-858-2060
Mailing Address - Fax:630-858-4025
Practice Address - Street 1:420 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4437
Practice Address - Country:US
Practice Address - Phone:630-858-2060
Practice Address - Fax:630-858-4025
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics