Provider Demographics
NPI:1952688004
Name:DOUGHERTY DENTISTRY, PLLC
Entity Type:Organization
Organization Name:DOUGHERTY DENTISTRY, PLLC
Other - Org Name:ROLLING OAKS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:210-722-1400
Mailing Address - Street 1:6826 N LOOP 1604 E
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-5328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6826 N LOOP 1604 E
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-5328
Practice Address - Country:US
Practice Address - Phone:210-722-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty