Healthcare Provider Details

I. General information

NPI: 1437484128
Provider Name (Legal Business Name): BETHANY ANN DOUGLAS D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2009
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9109 BAYMEADOWS RD STE 2
JACKSONVILLE FL
32256-1842
US

IV. Provider business mailing address

1060 OAKVALE RD
ST JOHNS FL
32259-3823
US

V. Phone/Fax

Practice location:
  • Phone: 904-265-1242
  • Fax:
Mailing address:
  • Phone: 904-671-3799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN014001
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN19093
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: