Provider Demographics
NPI:1699978429
Name:DOHERTY, MICAHEL JOSEPH (DDS)
Entity type:Individual
Prefix:DR
First Name:MICAHEL
Middle Name:JOSEPH
Last Name:DOHERTY
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 1:8824 LITZSINGER ROAD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2222
Mailing Address - Country:US
Mailing Address - Phone:314-961-3221
Mailing Address - Fax:314-961-7477
Practice Address - Street 1:8824 LITZSINGER RD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:MO
Practice Address - Zip Code:63144-2222
Practice Address - Country:US
Practice Address - Phone:314-961-3221
Practice Address - Fax:314-961-7477
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO14381122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist