Provider Demographics
NPI:1245332394
Name:DAUGHERTY, WARREN FREDERICK JR (DDS)
Entity type:Individual
Prefix:DR
First Name:WARREN
Middle Name:FREDERICK
Last Name:DAUGHERTY
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 HATHAWAY PARK
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-6163
Mailing Address - Country:US
Mailing Address - Phone:717-273-0411
Mailing Address - Fax:717-272-7099
Practice Address - Street 1:207 HATHAWAY PARK
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-6163
Practice Address - Country:US
Practice Address - Phone:717-273-0411
Practice Address - Fax:717-272-7099
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAD5015609L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1156932OtherMET LIFE
59606OtherUNITED CONCORDIA