Provider Demographics
NPI:1033241864
Name:DOUGHERTY, LAURA ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ANN
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 FOULK RD STE D
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-3700
Mailing Address - Country:US
Mailing Address - Phone:302-999-8113
Mailing Address - Fax:
Practice Address - Street 1:1601 MILLTOWN RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808
Practice Address - Country:US
Practice Address - Phone:302-999-8113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-000012361223G0001X
DEG1-0001236122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice