Provider Demographics
NPI:1861999864
Name:DOUGLAS, PETER (DDS)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:DOUGLAS
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 1:1204 SE 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4222
Mailing Address - Country:US
Mailing Address - Phone:712-560-6260
Mailing Address - Fax:
Practice Address - Street 1:10300 SE WASHINGTON ST STE C101
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2805
Practice Address - Country:US
Practice Address - Phone:503-776-3091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-07
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD119701223P0221X
WA610396001223P0221X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program