Provider Demographics
NPI:1164540696
Name:MARK A. DOUGHERTY, D.D.S., INC
Entity Type:Organization
Organization Name:MARK A. DOUGHERTY, D.D.S., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-993-1194
Mailing Address - Street 1:17300 YORBA LINDA BLVD STE H
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-3810
Mailing Address - Country:US
Mailing Address - Phone:714-993-1194
Mailing Address - Fax:714-524-0397
Practice Address - Street 1:17300 YORBA LINDA BLVD STE H
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-3810
Practice Address - Country:US
Practice Address - Phone:714-993-1194
Practice Address - Fax:714-524-0397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty