Provider Demographics
NPI:1205839651
Name:DOUGHTY, MICHAEL B (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:B
Last Name:DOUGHTY
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 1:1217 S 31ST ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504-6703
Mailing Address - Country:US
Mailing Address - Phone:254-774-9552
Mailing Address - Fax:254-774-9464
Practice Address - Street 1:1217 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-6703
Practice Address - Country:US
Practice Address - Phone:254-774-9552
Practice Address - Fax:254-774-9464
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2016-10-25
Deactivation Date:2005-05-31
Deactivation Code:
Reactivation Date:2007-05-30
Provider Licenses
StateLicense IDTaxonomies
TX177051223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics