Healthcare Provider Details

I. General information

NPI: 1376478131
Provider Name (Legal Business Name): DOUGLAS DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 W 700 S
EPHRAIM UT
84627-1524
US

IV. Provider business mailing address

41 W 700 S
EPHRAIM UT
84627-1524
US

V. Phone/Fax

Practice location:
  • Phone: 435-258-9001
  • Fax: 435-258-9002
Mailing address:
  • Phone: 435-258-9001
  • Fax: 435-258-9002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: COLTON C DOUGLAS
Title or Position: DENTISTRY/OWNER
Credential: DMD
Phone: 435-258-9001