Healthcare Provider Details

I. General information

NPI: 1164425161
Provider Name (Legal Business Name): DENNIS DAVID DOUGHTY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MAIN ST W
GIRARD PA
16417-1613
US

IV. Provider business mailing address

110 WALNUT ST
GIRARD PA
16417-1632
US

V. Phone/Fax

Practice location:
  • Phone: 814-774-9601
  • Fax: 814-774-2055
Mailing address:
  • Phone: 814-774-9318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS019608L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: