Provider Demographics
NPI:1831243393
Name:DOUGLAS, JOHN G (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:DOUGLAS
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 1:223 GARDENIA CT
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-8307
Mailing Address - Country:US
Mailing Address - Phone:717-330-2258
Mailing Address - Fax:717-509-6465
Practice Address - Street 1:223 GARDENIA CT
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543-8307
Practice Address - Country:US
Practice Address - Phone:717-330-2258
Practice Address - Fax:717-509-6465
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS027870L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist