MEDICARE: DR. CAROLYN JENNINGS SOUTHWORTH D.M.D., M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	8324	KY

General Provider Information

NPI Number	:	1275565970
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAROLYN JENNINGS SOUTHWORTH D.M.D., M.S.

Provider Business Mailing Address
First Line	:	209 HIGH POINT CT
Second Line	:	SUITE 200
City	:	MOUNT WASHINGTON
State	:	KY
Zip	:	40047-6563
Country	:	US
Telephone Number	:	502-538-6555
Fax Number	:	502-538-0657

Provider Business Practice Location Address
First Line	:	209 HIGH POINT CT
Second Line	:	SUITE 200
City	:	MOUNT WASHINGTON
State	:	KY
Zip	:	40047-6563
Country	:	US
Telephone Number	:	502-538-6555
Fax Number	:	502-538-0657

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	11/15/2011

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