Provider Demographics
NPI:1619407996
Name:CODY, KATELYN RAE (DDS)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:RAE
Last Name:CODY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 RIVERSIDE DRIVE #B417
Mailing Address - Street 2:
Mailing Address - City:UPPER ARLINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43220-6315
Mailing Address - Country:US
Mailing Address - Phone:419-480-9260
Mailing Address - Fax:
Practice Address - Street 1:2138 MADISON AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-5131
Practice Address - Country:US
Practice Address - Phone:419-241-6215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0251231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty