Provider Demographics
NPI:1386658466
Name:DAUGHERTY, TIMOTHY C (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:C
Last Name:DAUGHERTY
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 1:4801 MANSLICK RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-4097
Mailing Address - Country:US
Mailing Address - Phone:502-366-0737
Mailing Address - Fax:502-366-6299
Practice Address - Street 1:4801 MANSLICK RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-4097
Practice Address - Country:US
Practice Address - Phone:502-366-0737
Practice Address - Fax:502-366-6299
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY57981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice