Provider Demographics
NPI:1043374515
Name:DOUGHERTY, THOMAS PATRICK (DMD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:PATRICK
Last Name:DOUGHERTY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5317 LIMESTONE RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-1035
Mailing Address - Country:US
Mailing Address - Phone:302-239-2500
Mailing Address - Fax:
Practice Address - Street 1:5317 LIMESTONE RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-1252
Practice Address - Country:US
Practice Address - Phone:302-239-2500
Practice Address - Fax:302-239-0550
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG100009051223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000912501Medicaid
CT54490OtherAETNA
DEG02836T01Medicare PIN