Provider Demographics
NPI:1447318571
Name:DAUGHERTY, JOHN LEWIS IV (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LEWIS
Last Name:DAUGHERTY
Suffix:IV
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6490 E MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-2394
Mailing Address - Country:US
Mailing Address - Phone:614-866-3301
Mailing Address - Fax:
Practice Address - Street 1:6490 E MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-2394
Practice Address - Country:US
Practice Address - Phone:614-866-3301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2023-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0221211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2701339Medicaid