Provider Demographics
NPI:1013055300
Name:DOUGHERTY, RICK M (DDS, ABGD, NDBA)
Entity Type:Individual
Prefix:DR
First Name:RICK
Middle Name:M
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:DDS, ABGD, NDBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18301 N 79TH AVE
Mailing Address - Street 2:G-185
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8463
Mailing Address - Country:US
Mailing Address - Phone:623-931-9197
Mailing Address - Fax:623-937-4385
Practice Address - Street 1:18301 N 79TH AVE
Practice Address - Street 2:G-185
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8463
Practice Address - Country:US
Practice Address - Phone:623-931-9197
Practice Address - Fax:623-937-4385
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD33741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice