Provider Demographics
NPI:1760767958
Name:DOUGHERTY, THEODORE MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:MICHAEL
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 1:1812 GEORGIA AVE.
Mailing Address - Street 2:SUITE 110
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1437
Mailing Address - Country:US
Mailing Address - Phone:240-390-0276
Mailing Address - Fax:
Practice Address - Street 1:18121 GEORGIA AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1437
Practice Address - Country:US
Practice Address - Phone:240-390-0276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07093122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist