Provider Demographics
NPI:1053493486
Name:DAUGHERTY, LARRY D (DMD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:D
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 ISLAND PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-2879
Mailing Address - Country:US
Mailing Address - Phone:912-434-4121
Mailing Address - Fax:912-268-2847
Practice Address - Street 1:124 ISLAND PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522
Practice Address - Country:US
Practice Address - Phone:912-434-4121
Practice Address - Fax:912-268-2847
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA100201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice