Provider Demographics
NPI:1104949064
Name:KEVIN P. DOUGHERTY, DMD, PA
Entity type:Organization
Organization Name:KEVIN P. DOUGHERTY, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-377-3000
Mailing Address - Street 1:475 SHUNPIKE RD
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07928-1528
Mailing Address - Country:US
Mailing Address - Phone:973-377-3000
Mailing Address - Fax:973-377-0909
Practice Address - Street 1:475 SHUNPIKE RD
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:NJ
Practice Address - Zip Code:07928-1528
Practice Address - Country:US
Practice Address - Phone:973-377-3000
Practice Address - Fax:973-377-0909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD152051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty