Provider Demographics
NPI:1649369406
Name:KANE, DOUGLAS JOHN (DDS)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:JOHN
Last Name:KANE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 687
Mailing Address - Street 2:122 N MAIN ST
Mailing Address - City:EVART
Mailing Address - State:MI
Mailing Address - Zip Code:49631
Mailing Address - Country:US
Mailing Address - Phone:231-734-5621
Mailing Address - Fax:231-734-5851
Practice Address - Street 1:122 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EVART
Practice Address - State:MI
Practice Address - Zip Code:49631
Practice Address - Country:US
Practice Address - Phone:231-734-5621
Practice Address - Fax:231-734-5851
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID121931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice