Provider Demographics
NPI:1760462543
Name:DOUGHERTY, JOHN EUGENE (DMD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:EUGENE
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 NW DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2121
Mailing Address - Country:US
Mailing Address - Phone:503-221-1973
Mailing Address - Fax:
Practice Address - Street 1:1809 NW DAVIS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2121
Practice Address - Country:US
Practice Address - Phone:503-221-1973
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR47161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000NGPJMedicaid
OR0000NGPJMedicaid