Provider Demographics
NPI:1306902416
Name:JAMES D DOUGLASS DDS PA
Entity type:Organization
Organization Name:JAMES D DOUGLASS DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-323-8254
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28302-1449
Mailing Address - Country:US
Mailing Address - Phone:910-323-8254
Mailing Address - Fax:910-323-2532
Practice Address - Street 1:101 WALL ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-4761
Practice Address - Country:US
Practice Address - Phone:910-323-8254
Practice Address - Fax:910-323-2532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-01
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5950576Medicaid
NC809135OtherUNITED CONCORDIA
NC92191OtherBLUE CROSS BLUE SHIELD