Provider Demographics
NPI:1861430746
Name:DAUGHERTY, MICHAEL SHANNON (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHANNON
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
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Mailing Address - Street 1:200 GROVE PARK LN
Mailing Address - Street 2:SUITE 600
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-5911
Mailing Address - Country:US
Mailing Address - Phone:334-699-3636
Mailing Address - Fax:334-699-3637
Practice Address - Street 1:1805 W MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1343
Practice Address - Country:US
Practice Address - Phone:334-699-3636
Practice Address - Fax:334-699-3637
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ALAL-49121223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics