Provider Demographics
NPI:1184601965
Name:DOUGHERTY, STEFANIE BROOKE (DMD, MSD)
Entity type:Individual
Prefix:DR
First Name:STEFANIE
Middle Name:BROOKE
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 DOUGHERTY FERRY RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-3368
Mailing Address - Country:US
Mailing Address - Phone:636-825-1000
Mailing Address - Fax:636-825-1040
Practice Address - Street 1:2901 DOUGHERTY FERRY RD
Practice Address - Street 2:SUITE 301
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-3368
Practice Address - Country:US
Practice Address - Phone:636-825-1000
Practice Address - Fax:636-825-1040
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004016350122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist