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General NPI Number Information
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NPI Number | 1568773760
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Entity Type | Individual
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Provider Name | MATTHEW STEVEN DAUGHERTY DDS
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Gender | Male
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Dates
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Enumeration Date | 06/23/2010
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Last Update Date | 03/23/2022
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Provider Practice Location Address
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Address Line | 1900 E MAIN ST
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City | DANVILLE
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State | IL
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Zip | 61832-5100
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Country | US
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Telephone | 217-554-5857
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Fax |
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Provider Business Mailing Address
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Address Line | 2506 MONICA LN
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City | BLOOMINGTON
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State | IL
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Zip | 61705-4131
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Country | US
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Telephone | 205-343-4686
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2901020200
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License Number State | MI
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