Provider Demographics
NPI:1407285869
Name:CLOUGHLEY, DOREEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:DOREEN
Middle Name:
Last Name:CLOUGHLEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 HALLOCK RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 HALLOCK RD
Practice Address - Street 2:SUITE 5
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3033
Practice Address - Country:US
Practice Address - Phone:631-751-7645
Practice Address - Fax:631-751-4170
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047430122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist