Provider Demographics
NPI:1043903073
Name:DAUGHERTY, CONNOR MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:MICHAEL
Last Name:DAUGHERTY
Suffix:
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 1:2112 S ATLANTA PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-1709
Mailing Address - Country:US
Mailing Address - Phone:580-548-3354
Mailing Address - Fax:
Practice Address - Street 1:2112 S ATLANTA PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-1709
Practice Address - Country:US
Practice Address - Phone:580-548-3354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK76971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice