Provider Demographics
NPI:1275880742
Name:VALDERRAMA DOUGHERTY, NATALIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:NATALIA
Middle Name:
Last Name:VALDERRAMA DOUGHERTY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:976 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-1506
Mailing Address - Country:US
Mailing Address - Phone:904-434-7783
Mailing Address - Fax:
Practice Address - Street 1:903 JORDAN BLASS DR STE 102
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-1325
Practice Address - Country:US
Practice Address - Phone:321-544-4127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN196511223G0001X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice