1477991552 NPI number — DR. MARY CATHERINE BLOSSOM DMD

Table of content: DR. MARY CATHERINE BLOSSOM DMD (NPI 1477991552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477991552 NPI number — DR. MARY CATHERINE BLOSSOM DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOSSOM
Provider First Name:
MARY
Provider Middle Name:
CATHERINE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STONE
Provider Other First Name:
MARY
Provider Other Middle Name:
CATHERINE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477991552
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
233 WOODLAND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39117-3711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-732-6200
Provider Business Mailing Address Fax Number:
601-732-6624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
233 WOODLAND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39117-3711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-732-6200
Provider Business Practice Location Address Fax Number:
601-632-6624
Provider Enumeration Date:
06/11/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  369913 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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