MEDICARE: DR. DOUGLAS ALAN KELLOGG D.D.S.

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	5307	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5307	OTHER	NC	DENTAL LICENSE

General Provider Information

NPI Number	:	1922142249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS ALAN KELLOGG D.D.S.

Provider Business Mailing Address
First Line	:	2733 HORSE PEN CREEK RD
Second Line	:	SUITE 107
City	:	GREENSBORO
State	:	NC
Zip	:	27410-8399
Country	:	US
Telephone Number	:	336-854-9270
Fax Number	:	336-854-5628

Provider Business Practice Location Address
First Line	:	2733 HORSE PEN CREEK RD
Second Line	:	SUITE 107
City	:	GREENSBORO
State	:	NC
Zip	:	27410-8399
Country	:	US
Telephone Number	:	336-854-9270
Fax Number	:	336-854-5628

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

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	07/08/2007

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