Healthcare Provider Details

I. General information

NPI: 1215066741
Provider Name (Legal Business Name): DOUGLAS RAYMOND PICK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 06/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 NW 142ND ST STE 201
CLIVE IA
50325-8346
US

IV. Provider business mailing address

1250 NW 142ND ST STE 201
CLIVE IA
50325-8346
US

V. Phone/Fax

Practice location:
  • Phone: 515-222-0505
  • Fax: 515-222-9942
Mailing address:
  • Phone: 515-222-0505
  • Fax: 515-222-9942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number06598
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: