Provider Demographics
NPI:1114097482
Name:DOHERTY, MICHAEL DENNIS (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DENNIS
Last Name:DOHERTY
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 1:580 MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CARBONDALE
Mailing Address - State:CO
Mailing Address - Zip Code:81623-2072
Mailing Address - Country:US
Mailing Address - Phone:970-963-4882
Mailing Address - Fax:970-963-1023
Practice Address - Street 1:580 MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CARBONDALE
Practice Address - State:CO
Practice Address - Zip Code:81623-2072
Practice Address - Country:US
Practice Address - Phone:970-963-4882
Practice Address - Fax:970-963-1023
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO67151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice