Provider Demographics
NPI:1043565807
Name:DOUGHERTY, ERIN JEANNE (DMD)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:JEANNE
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-7031
Mailing Address - Country:US
Mailing Address - Phone:727-608-4690
Mailing Address - Fax:
Practice Address - Street 1:822 MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-7031
Practice Address - Country:US
Practice Address - Phone:727-608-4690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19885122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006435100Medicaid