Provider Demographics
NPI:1336832930
Name:DOUGHTY, MEGAN
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:DOUGHTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W286S4560 WOODS RD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-9050
Mailing Address - Country:US
Mailing Address - Phone:262-894-6160
Mailing Address - Fax:
Practice Address - Street 1:1149 BOUGHTON ST BLDG B
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-3104
Practice Address - Country:US
Practice Address - Phone:920-261-0495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001167-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist