Healthcare Provider Details

I. General information

NPI: 1386634418
Provider Name (Legal Business Name): MICHAEL J DOHERTY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 MURPHY ROAD
MEDFORD OR
97504
US

IV. Provider business mailing address

460 MURPHY ROAD
MEDFORD OR
97504
US

V. Phone/Fax

Practice location:
  • Phone: 541-776-0050
  • Fax: 541-776-0062
Mailing address:
  • Phone: 541-776-0050
  • Fax: 541-776-0062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD-3364
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: