Provider Demographics
NPI:1164037453
Name:PACE, MARY KATE (RDH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATE
Last Name:PACE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2291 HARLAN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-7301
Mailing Address - Country:US
Mailing Address - Phone:850-543-5529
Mailing Address - Fax:
Practice Address - Street 1:1115 N EGLIN PKWY
Practice Address - Street 2:
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-1228
Practice Address - Country:US
Practice Address - Phone:850-651-2199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-13
Last Update Date:2020-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH18814124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist