Provider Demographics
NPI:1033220892
Name:DOERSCH, MARY KAY (DDS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAY
Last Name:DOERSCH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:KAY
Other - Last Name:CLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1607 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701
Mailing Address - Country:US
Mailing Address - Phone:304-324-8703
Mailing Address - Fax:304-324-8735
Practice Address - Street 1:1607 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701
Practice Address - Country:US
Practice Address - Phone:304-324-8703
Practice Address - Fax:304-324-8735
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3246122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4001019000Medicaid