Provider Demographics
NPI:1578587382
Name:DOUGHERTY, THOMAS ROY (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ROY
Last Name:DOUGHERTY
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 1:618 W MAIN ST STE E-101
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-3773
Mailing Address - Country:US
Mailing Address - Phone:281-332-7679
Mailing Address - Fax:281-338-4439
Practice Address - Street 1:618 W MAIN ST STE E-101
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-3773
Practice Address - Country:US
Practice Address - Phone:281-332-7679
Practice Address - Fax:281-338-4439
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX138601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice