Provider Demographics
NPI:1538221429
Name:JOHN L DAUGHERTY DDS LLC
Entity type:Organization
Organization Name:JOHN L DAUGHERTY DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:IV
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-237-1008
Mailing Address - Street 1:2691 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BEXLEY
Mailing Address - State:OH
Mailing Address - Zip Code:43209-2535
Mailing Address - Country:US
Mailing Address - Phone:614-237-1008
Mailing Address - Fax:614-237-3057
Practice Address - Street 1:2691 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BEXLEY
Practice Address - State:OH
Practice Address - Zip Code:43209-2535
Practice Address - Country:US
Practice Address - Phone:614-237-1008
Practice Address - Fax:614-237-3057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2012-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30022121122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty