Provider Demographics
NPI:1962423541
Name:PSOTA DOUGHERTY, JENNIFER (DDS)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:PSOTA DOUGHERTY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:PSOTA
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:2255 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-4102
Mailing Address - Country:US
Mailing Address - Phone:440-835-0011
Mailing Address - Fax:440-250-1896
Practice Address - Street 1:7123 PEARL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-4975
Practice Address - Country:US
Practice Address - Phone:440-888-6783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21039122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist