Provider Demographics
NPI:1881663383
Name:DOHERTY, ROBERT (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
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 1:7 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:SNOW HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28580-1332
Mailing Address - Country:US
Mailing Address - Phone:252-747-8162
Mailing Address - Fax:252-747-8163
Practice Address - Street 1:6 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:SNOW HILL
Practice Address - State:NC
Practice Address - Zip Code:28580-1333
Practice Address - Country:US
Practice Address - Phone:252-747-3846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC68151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89902K1Medicaid