Provider Demographics
NPI:1235405424
Name:DELOACH, MARY KATHRYN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY KATHRYN
Middle Name:
Last Name:DELOACH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 EASTWOOD DR
Mailing Address - Street 2:309
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-4497
Mailing Address - Country:US
Mailing Address - Phone:203-623-6193
Mailing Address - Fax:
Practice Address - Street 1:60 TIMBER LN
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7214
Practice Address - Country:US
Practice Address - Phone:802-864-6881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-01
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT390200000X
VT016.00955051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program