MEDICARE: WERONIKA PAULA DOUGLAS D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	32847	TX
2	122300000X	Dentist	32847	TX

General Provider Information

NPI Number	:	1275061822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WERONIKA PAULA DOUGLAS D.D.S.

Provider Business Mailing Address
First Line	:	11052 S SHILLING AVE APT 3413
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84095-4239
Country	:	US
Telephone Number	:	915-633-5409
Fax Number	:

Provider Business Practice Location Address
First Line	:	3650 JOE BATTLE BLVD
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79938-2628
Country	:	US
Telephone Number	:	915-858-6868
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2017
Last Update Date	:	06/30/2021

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Directions to “ WERONIKA PAULA DOUGLAS D.D.S.” Practice Location

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