Healthcare Provider Details

I. General information

NPI: 1497432033
Provider Name (Legal Business Name): MCKENZIE LEIGH DAUGHERTY DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2023
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 CHURCH ST
BROADWAY NC
27505-9394
US

IV. Provider business mailing address

120 S BREAM CT
ANGIER NC
27501-6317
US

V. Phone/Fax

Practice location:
  • Phone: 919-258-9321
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14739
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: