1922142249 NPI number — DR. DOUGLAS ALAN KELLOGG D.D.S.

Table of content: DR. DOUGLAS ALAN KELLOGG D.D.S. (NPI 1922142249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922142249 NPI number — DR. DOUGLAS ALAN KELLOGG D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLOGG
Provider First Name:
DOUGLAS
Provider Middle Name:
ALAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922142249
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2733 HORSE PEN CREEK RD
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27410-8399
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-854-9270
Provider Business Mailing Address Fax Number:
336-854-5628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2733 HORSE PEN CREEK RD
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27410-8399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-854-9270
Provider Business Practice Location Address Fax Number:
336-854-5628
Provider Enumeration Date:
02/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5307 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5307 . This is a "DENTAL LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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