Provider Demographics
NPI:1245403286
Name:THOMAS P DOUGHERTY ORAL MAXILLOFACIAL SURGERY PA
Entity Type:Organization
Organization Name:THOMAS P DOUGHERTY ORAL MAXILLOFACIAL SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL MAXILLOFACIAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-239-2500
Mailing Address - Street 1:5317 LIMESTONE RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-1252
Mailing Address - Country:US
Mailing Address - Phone:302-239-2500
Mailing Address - Fax:302-239-0552
Practice Address - Street 1:5317 LIMESTONE RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-1252
Practice Address - Country:US
Practice Address - Phone:302-239-2500
Practice Address - Fax:302-239-0552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000912501Medicaid
DE54490OtherAETNA
DE0000912501Medicaid