Provider Demographics
NPI:1508874413
Name:HORUTZ, KATHRYN L (DMD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:HORUTZ
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 1:173 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-5728
Mailing Address - Country:US
Mailing Address - Phone:207-772-1205
Mailing Address - Fax:207-773-7414
Practice Address - Street 1:173 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-5728
Practice Address - Country:US
Practice Address - Phone:207-772-1205
Practice Address - Fax:207-773-7414
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH32411223G0001X
ME40121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30302635Medicaid
02Y003864NH01OtherANTHEM BLUE CROSS BLUE SH