MEDICARE: DR. JOHN P DOUGHERTY D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4252	AZ

General Provider Information

NPI Number	:	1982761755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN P DOUGHERTY D.D.S

Provider Business Mailing Address
First Line	:	2333 E CAMPBELL AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-5525
Country	:	US
Telephone Number	:	602-840-5400
Fax Number	:	602-956-0185

Provider Business Practice Location Address
First Line	:	2333 E CAMPBELL AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-5525
Country	:	US
Telephone Number	:	602-840-5400
Fax Number	:	602-956-0185

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	07/08/2007

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