Provider Demographics
NPI:1861874851
Name:MESSICK, DOUGLAS J (DDS)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:MESSICK
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 1:553 E 1000 N
Mailing Address - Street 2:
Mailing Address - City:FIRTH
Mailing Address - State:ID
Mailing Address - Zip Code:83236-1103
Mailing Address - Country:US
Mailing Address - Phone:208-680-6750
Mailing Address - Fax:
Practice Address - Street 1:3 E CENTER ST
Practice Address - Street 2:
Practice Address - City:SUGAR CITY
Practice Address - State:ID
Practice Address - Zip Code:83448-1247
Practice Address - Country:US
Practice Address - Phone:208-656-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID47501223G0001X
MT96241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice