Provider Demographics
NPI:1902543630
Name:BYRUM, MARY KRISTINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:KRISTINE
Last Name:BYRUM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 FOUNDERS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-7017
Mailing Address - Country:US
Mailing Address - Phone:614-949-6396
Mailing Address - Fax:
Practice Address - Street 1:17500 MADISON AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44107-3653
Practice Address - Country:US
Practice Address - Phone:216-302-2401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-15
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH004460390200000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program