Provider Demographics
NPI:1730420092
Name:WURTH, MARY CATHERINE (DMD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:WURTH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CATHERINE
Other - Last Name:CORRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 BOGLE ST STE 204
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-2850
Mailing Address - Country:US
Mailing Address - Phone:606-802-7891
Mailing Address - Fax:
Practice Address - Street 1:401 BOGLE ST STE 204
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2850
Practice Address - Country:US
Practice Address - Phone:606-802-7891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-12
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY92731223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100244450Medicaid