Provider Demographics
NPI:1598891012
Name:DAUGHERTY, DWIGHT RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:RICHARD
Last Name:DAUGHERTY
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 1:3016 N KENTWOOD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803
Mailing Address - Country:US
Mailing Address - Phone:417-833-1474
Mailing Address - Fax:
Practice Address - Street 1:3016 N KENTWOOD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803
Practice Address - Country:US
Practice Address - Phone:417-833-1474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO014206122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist