Healthcare Provider Details

I. General information

NPI: 1114097482
Provider Name (Legal Business Name): MICHAEL DENNIS DOHERTY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 MAIN ST SUITE 200
CARBONDALE CO
81623-2072
US

IV. Provider business mailing address

580 MAIN ST SUITE 200
CARBONDALE CO
81623-2072
US

V. Phone/Fax

Practice location:
  • Phone: 970-963-4882
  • Fax: 970-963-1023
Mailing address:
  • Phone: 970-963-4882
  • Fax: 970-963-1023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6715
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: