Healthcare Provider Details

I. General information

NPI: 1730420092
Provider Name (Legal Business Name): MARY CATHERINE WURTH DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY CATHERINE CORRELL

II. Dates (important events)

Enumeration Date: 03/12/2013
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BOGLE ST STE 204
SOMERSET KY
42503-2850
US

IV. Provider business mailing address

401 BOGLE ST STE 204
SOMERSET KY
42503-2850
US

V. Phone/Fax

Practice location:
  • Phone: 606-802-7891
  • Fax:
Mailing address:
  • Phone: 606-802-7891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number9273
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: