Provider Demographics
NPI:1003077108
Name:DOHERTY, S ADELE
Entity Type:Individual
Prefix:
First Name:S
Middle Name:ADELE
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:AGBOOLA
Other - Middle Name:ADESEGUN
Other - Last Name:ADELE-DOHERTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 646
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37121-0646
Mailing Address - Country:US
Mailing Address - Phone:615-851-4744
Mailing Address - Fax:
Practice Address - Street 1:107 NEW BRICK CHURCH PIKE
Practice Address - Street 2:SUITE C
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-1545
Practice Address - Country:US
Practice Address - Phone:615-851-4744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4679122300000X
DC5475122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5870Medicaid