Healthcare Provider Details

I. General information

NPI: 1649369406
Provider Name (Legal Business Name): DOUGLAS JOHN KANE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 N MAIN ST
EVART MI
49631
US

IV. Provider business mailing address

PO BOX 687 122 N MAIN ST
EVART MI
49631
US

V. Phone/Fax

Practice location:
  • Phone: 231-734-5621
  • Fax: 231-734-5851
Mailing address:
  • Phone: 231-734-5621
  • Fax: 231-734-5851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD12193
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: