Healthcare Provider Details

I. General information

NPI: 1780716183
Provider Name (Legal Business Name): ROBERT J DOHERTY DDS PC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 MAMARONECK AVE SUITE #210
WHITE PLAINS NY
10605-1438
US

IV. Provider business mailing address

280 MAMARONECK AVE SUITE #210
WHITE PLAINS NY
10605-1438
US

V. Phone/Fax

Practice location:
  • Phone: 914-948-3883
  • Fax:
Mailing address:
  • Phone: 914-948-3883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number28025
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: