=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992077200
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWARD T DOUGHERTY JR. D.D.S
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2012
-----------------------------------------------------
Last Update Date | 02/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12308 OCEAN GTWY
-----------------------------------------------------
City | OCEAN CITY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21842-9341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-213-1482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36872 JAHNIGEN DR
-----------------------------------------------------
City | FRANKFORD
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19945-4590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-213-1482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | MD6401
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | G1-0001178
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------