Provider Demographics
NPI:1730399577
Name:PRINCE, DOUGLAS RUSSELL (DMD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:RUSSELL
Last Name:PRINCE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 S DURANGO DR
Mailing Address - Street 2:SUITE #104
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-2486
Mailing Address - Country:US
Mailing Address - Phone:702-240-0202
Mailing Address - Fax:702-240-2392
Practice Address - Street 1:830 S DURANGO DR
Practice Address - Street 2:SUITE #104
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-2486
Practice Address - Country:US
Practice Address - Phone:702-240-0202
Practice Address - Fax:702-240-2392
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV26381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice