Provider Demographics
NPI:1780637736
Name:DOHERTY, NICOLE (DMD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DOHERTY
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 1:926 GREAT POND DR
Mailing Address - Street 2:SUITE 2003
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-7244
Mailing Address - Country:US
Mailing Address - Phone:407-772-5124
Mailing Address - Fax:407-788-3572
Practice Address - Street 1:2641 S WOODLAND BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-8601
Practice Address - Country:US
Practice Address - Phone:386-738-7441
Practice Address - Fax:386-738-1299
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN159631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice