Provider Demographics
NPI:1992714349
Name:SCHULTZ, DOUGLAS VAUGHN (DDS)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:VAUGHN
Last Name:SCHULTZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 N SANGAMON AVE
Mailing Address - Street 2:
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936-1256
Mailing Address - Country:US
Mailing Address - Phone:217-784-5133
Mailing Address - Fax:217-784-8460
Practice Address - Street 1:330 N SANGAMON AVE
Practice Address - Street 2:
Practice Address - City:GIBSON CITY
Practice Address - State:IL
Practice Address - Zip Code:60936-1256
Practice Address - Country:US
Practice Address - Phone:217-784-5133
Practice Address - Fax:217-784-8460
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice