Healthcare Provider Details

I. General information

NPI: 1932108446
Provider Name (Legal Business Name): EDWARD T DOUGHERTY JR DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 12/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12308 OCEAN GTWY SUITE #6
OCEAN CITY MD
21842-9341
US

IV. Provider business mailing address

36872 JAHNIGEN DR
FRANKFORD DE
19945-4590
US

V. Phone/Fax

Practice location:
  • Phone: 410-390-2220
  • Fax: 410-213-2955
Mailing address:
  • Phone: 410-390-2220
  • Fax: 410-212-2955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberG401
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberG1-0001178X
License Number StateDE

VIII. Authorized Official

Name: DR. EDWARD T DOUGHERTY JR.
Title or Position: PRESIDENT
Credential: DDS
Phone: 410-390-2220