Provider Demographics
NPI:1750646188
Name:DOROGHAZI, BETHANY L (DMD)
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:L
Last Name:DOROGHAZI
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 1:6815 THORNAPPLE DR
Mailing Address - Street 2:
Mailing Address - City:GATES MILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44040-9644
Mailing Address - Country:US
Mailing Address - Phone:440-488-6744
Mailing Address - Fax:
Practice Address - Street 1:8300 HOUGH AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-4247
Practice Address - Country:US
Practice Address - Phone:216-231-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2017-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-023688122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0089125Medicaid