Provider Demographics
NPI:1932108446
Name:EDWARD T DOUGHERTY JR DDS PC
Entity Type:Organization
Organization Name:EDWARD T DOUGHERTY JR DDS PC
Other - Org Name:DELMARVA SEDATION DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-390-2220
Mailing Address - Street 1:36872 JAHNIGEN DR
Mailing Address - Street 2:
Mailing Address - City:FRANKFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19945-4590
Mailing Address - Country:US
Mailing Address - Phone:410-390-2220
Mailing Address - Fax:410-212-2955
Practice Address - Street 1:12308 OCEAN GTWY
Practice Address - Street 2:SUITE #6
Practice Address - City:OCEAN CITY
Practice Address - State:MD
Practice Address - Zip Code:21842-9341
Practice Address - Country:US
Practice Address - Phone:410-390-2220
Practice Address - Fax:410-213-2955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDG4011223D0001X
DEG1-0001178X1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD7368050001Medicare NSC