Healthcare Provider Details

I. General information

NPI: 1417090077
Provider Name (Legal Business Name): KATHERINE PATE PUGH RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 RAMSEY ST DENTAL SERVICE (160)
FAYETTEVILLE NC
28301-3856
US

IV. Provider business mailing address

4204 KIRKWOOD PL
FAYETTEVILLE NC
28303-4919
US

V. Phone/Fax

Practice location:
  • Phone: 910-822-7029
  • Fax:
Mailing address:
  • Phone: 910-868-4008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number1767
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: