Provider Demographics
NPI:1932657731
Name:DOUGHERTY, WENDY (RDH)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 OLD HOMESTEAD DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97462-9546
Mailing Address - Country:US
Mailing Address - Phone:541-643-4474
Mailing Address - Fax:
Practice Address - Street 1:2700 NW STEWART PKWY
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1281
Practice Address - Country:US
Practice Address - Phone:541-643-4474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH5059124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist