Provider Demographics
NPI:1548494420
Name:DOUGLAS, ABBY R (DENTAL HYGIENE)
Entity type:Individual
Prefix:
First Name:ABBY
Middle Name:R
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:DENTAL HYGIENE
Other - Prefix:
Other - First Name:ABBY
Other - Middle Name:R
Other - Last Name:KOMPROOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:74 ECLIPSE CTR
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-3550
Mailing Address - Country:US
Mailing Address - Phone:608-361-0311
Mailing Address - Fax:608-361-0312
Practice Address - Street 1:435 MAIN ST
Practice Address - Street 2:
Practice Address - City:DARLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53530-1427
Practice Address - Country:US
Practice Address - Phone:608-776-2082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6596-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist