Provider Demographics
NPI:1417005083
Name:DOUGHERTY, HARRY L JR (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:HARRY
Middle Name:L
Last Name:DOUGHERTY
Suffix:JR
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:4955 VAN NUYS BLVD
Mailing Address - Street 2:SUITE 606
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1801
Mailing Address - Country:US
Mailing Address - Phone:818-986-6223
Mailing Address - Fax:818-986-6244
Practice Address - Street 1:4955 VAN NUYS BLVD
Practice Address - Street 2:SUITE 606
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1801
Practice Address - Country:US
Practice Address - Phone:818-986-6223
Practice Address - Fax:818-986-6244
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA337111223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics