Provider Demographics
NPI:1477902815
Name:PARKER, KATHY
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:PARKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3307 HUMMINGBIRD CT
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-7127
Mailing Address - Country:US
Mailing Address - Phone:706-536-7651
Mailing Address - Fax:
Practice Address - Street 1:2828 SIGHTSEEING RD
Practice Address - Street 2:
Practice Address - City:FT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:706-545-4627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYXXXXX125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist