Provider Demographics
NPI:1083625347
Name:DAUGHERTY, LISA L (DMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:L
Last Name:DAUGHERTY
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 1:207A ALPINE DR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-8881
Mailing Address - Country:US
Mailing Address - Phone:502-633-3900
Mailing Address - Fax:502-633-3999
Practice Address - Street 1:207A ALPINE DR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-8881
Practice Address - Country:US
Practice Address - Phone:502-633-3900
Practice Address - Fax:502-633-3999
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY77551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice