Provider Demographics
NPI:1396870317
Name:INGRAM AND DAUGHERTY ORTHODONTISTS, LLC
Entity type:Organization
Organization Name:INGRAM AND DAUGHERTY ORTHODONTISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, CERT ORTHODONT
Authorized Official - Phone:717-274-2913
Mailing Address - Street 1:710 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-6901
Mailing Address - Country:US
Mailing Address - Phone:717-274-2913
Mailing Address - Fax:
Practice Address - Street 1:710 S 12TH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-6901
Practice Address - Country:US
Practice Address - Phone:717-274-2913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS020047L1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADS020047LOtherDR INGRAMS STATE LICENSE