Provider Demographics
NPI:1174532907
Name:DOUGHERTY, JOHN DENNIS (DMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DENNIS
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:D
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD & ASSOC
Mailing Address - Street 1:27 N MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAINTOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707-1116
Mailing Address - Country:US
Mailing Address - Phone:570-474-5923
Mailing Address - Fax:570-403-5484
Practice Address - Street 1:27 N MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAINTOP
Practice Address - State:PA
Practice Address - Zip Code:18707-1116
Practice Address - Country:US
Practice Address - Phone:570-474-5923
Practice Address - Fax:570-403-5484
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA18129122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
510561OtherUNITED CONCORDIA