Provider Demographics
NPI:1205999133
Name:MAXWELL, DOUGLAS COURTNEY (DMD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:COURTNEY
Last Name:MAXWELL
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 1:2415 ANDOVER DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1280
Mailing Address - Country:US
Mailing Address - Phone:229-671-1900
Mailing Address - Fax:229-671-1999
Practice Address - Street 1:2415 ANDOVER DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1280
Practice Address - Country:US
Practice Address - Phone:229-671-1900
Practice Address - Fax:229-671-1999
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11562122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9183256OtherDORAL
GA000963256AMedicaid
GA986622OtherUNITED CONCORDIA
GA100049OtherAVESIS