Provider Demographics
NPI:1790472207
Name:DOHERTY, CONNOR THOMAS (DDS)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:THOMAS
Last Name:DOHERTY
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 1:567 S SIERRA AVE UNIT 75
Mailing Address - Street 2:
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-2238
Mailing Address - Country:US
Mailing Address - Phone:917-536-6518
Mailing Address - Fax:
Practice Address - Street 1:770 ROSE STREET
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:859-323-6080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program