MEDICARE: DR. RICKEY BRENT DOUGLAS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	2272	AR

General Provider Information

NPI Number	:	1134174428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICKEY BRENT DOUGLAS DDS

Provider Business Mailing Address
First Line	:	1607 MAIN ST
Second Line	:
City	:	VAN BUREN
State	:	AR
Zip	:	72956-4735
Country	:	US
Telephone Number	:	479-474-7076
Fax Number	:	479-471-1868

Provider Business Practice Location Address
First Line	:	1607 MAIN ST
Second Line	:
City	:	VAN BUREN
State	:	AR
Zip	:	72956-4735
Country	:	US
Telephone Number	:	479-474-7076
Fax Number	:	479-471-1868

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. RICKEY BRENT DOUGLAS DDS” Practice Location

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