MEDICARE: DOUGLAS DENTISTRY, LLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1376478131
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOUGLAS DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	41 W 700 S
Second Line	:
City	:	EPHRAIM
State	:	UT
Zip	:	84627-1524
Country	:	US
Telephone Number	:	435-258-9001
Fax Number	:	435-258-9002

Provider Business Practice Location Address
First Line	:	41 W 700 S
Second Line	:
City	:	EPHRAIM
State	:	UT
Zip	:	84627-1524
Country	:	US
Telephone Number	:	435-258-9001
Fax Number	:	435-258-9002

Authorized Official
Title or Position	:	DENTISTRY/OWNER
Name	:	COLTON C DOUGLAS
Credential	:	DMD
Telephone Number	:	435-258-9001

Provider Enumeration Date	:	06/15/2026
Last Update Date	:	06/15/2026

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