Provider Demographics
NPI:1992077200
Name:DOUGHERTY, EDWARD T JR (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:T
Last Name:DOUGHERTY
Suffix:JR
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 1:36872 JAHNIGEN DR
Mailing Address - Street 2:
Mailing Address - City:FRANKFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19945-4590
Mailing Address - Country:US
Mailing Address - Phone:410-213-1482
Mailing Address - Fax:
Practice Address - Street 1:12308 OCEAN GTWY
Practice Address - Street 2:
Practice Address - City:OCEAN CITY
Practice Address - State:MD
Practice Address - Zip Code:21842-9341
Practice Address - Country:US
Practice Address - Phone:410-213-1482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMD64011223G0001X
DEG1-00011781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice