Provider Demographics
NPI:1225102395
Name:DOUGLASS, TABITHA ANNETTE
Entity type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:ANNETTE
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 STONEWALL DRIVE
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980
Mailing Address - Country:US
Mailing Address - Phone:540-943-2859
Mailing Address - Fax:
Practice Address - Street 1:113 STONEWALL DRIVE
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980
Practice Address - Country:US
Practice Address - Phone:540-943-2859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402202943124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist