Provider Demographics
NPI:1275565970
Name:SOUTHWORTH, CAROLYN JENNINGS (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:JENNINGS
Last Name:SOUTHWORTH
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:DR
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:JENNINGS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:209 HIGH POINT CT
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MOUNT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-6563
Mailing Address - Country:US
Mailing Address - Phone:502-538-6555
Mailing Address - Fax:502-538-0657
Practice Address - Street 1:209 HIGH POINT CT
Practice Address - Street 2:SUITE 200
Practice Address - City:MOUNT WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047-6563
Practice Address - Country:US
Practice Address - Phone:502-538-6555
Practice Address - Fax:502-538-0657
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY83241223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics