Provider Demographics
NPI:1407159320
Name:JENNIFER PSOTA DOUGHERTY DDS LLC
Entity Type:Organization
Organization Name:JENNIFER PSOTA DOUGHERTY DDS LLC
Other - Org Name:WESTLAKE FAMILY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:PSOTA DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:440-835-0011
Mailing Address - Street 1:2255 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-4102
Mailing Address - Country:US
Mailing Address - Phone:440-835-0011
Mailing Address - Fax:440-250-1896
Practice Address - Street 1:2255 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-4102
Practice Address - Country:US
Practice Address - Phone:440-835-0011
Practice Address - Fax:440-250-1896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-15
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21039122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty