Provider Demographics
NPI:1386732501
Name:DAUGHERTY, JOHN MICHAEL (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8900 PENN AVE S
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-2068
Mailing Address - Country:US
Mailing Address - Phone:952-888-1861
Mailing Address - Fax:952-888-1883
Practice Address - Street 1:8900 PENN AVE S
Practice Address - Street 2:SUITE 202
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-2068
Practice Address - Country:US
Practice Address - Phone:952-888-1861
Practice Address - Fax:952-888-1883
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN74081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice