Healthcare Provider Details

I. General information

NPI: 1861874851
Provider Name (Legal Business Name): DOUGLAS J MESSICK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 07/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 E CENTER ST
SUGAR CITY ID
83448-1247
US

IV. Provider business mailing address

553 E 1000 N
FIRTH ID
83236-1103
US

V. Phone/Fax

Practice location:
  • Phone: 208-656-2000
  • Fax:
Mailing address:
  • Phone: 208-680-6750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4750
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9624
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: