Provider Demographics
NPI:1386634418
Name:DOHERTY, MICHAEL J (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
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 1:460 MURPHY ROAD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504
Mailing Address - Country:US
Mailing Address - Phone:541-776-0050
Mailing Address - Fax:541-776-0062
Practice Address - Street 1:460 MURPHY ROAD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-776-0050
Practice Address - Fax:541-776-0062
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-33641223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery