Provider Demographics
NPI:1780716183
Name:DOHERTY, ROBERT J (DDS PC)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 MAMARONECK AVE
Mailing Address - Street 2:SUITE #210
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-1438
Mailing Address - Country:US
Mailing Address - Phone:914-948-3883
Mailing Address - Fax:
Practice Address - Street 1:280 MAMARONECK AVE
Practice Address - Street 2:SUITE #210
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-1438
Practice Address - Country:US
Practice Address - Phone:914-948-3883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280251223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD95011Medicare PIN