Provider Demographics
NPI:1871693374
Name:KALLIS, DOUGLAS CHARLES (DMD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:CHARLES
Last Name:KALLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:218 ADDAVALE ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4217
Mailing Address - Country:US
Mailing Address - Phone:770-227-1296
Mailing Address - Fax:770-228-5262
Practice Address - Street 1:218 ADDAVALE ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4217
Practice Address - Country:US
Practice Address - Phone:770-227-1296
Practice Address - Fax:770-228-5262
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA108511223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics