Provider Demographics
NPI:1932451267
Name:DAUGHERTY, KEVIN D (DMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 US 31W BYP STE 101
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-4963
Mailing Address - Country:US
Mailing Address - Phone:270-783-5280
Mailing Address - Fax:
Practice Address - Street 1:8453 NASHVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-8721
Practice Address - Country:US
Practice Address - Phone:270-707-0292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9368122300000X
KY103151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist