Provider Demographics
NPI:1790051340
Name:TOURTLOTTE, MARY KATHERINE (DDS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:TOURTLOTTE
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 1:1473 E G ST
Mailing Address - Street 2:STE C
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-4205
Mailing Address - Country:US
Mailing Address - Phone:209-848-8074
Mailing Address - Fax:
Practice Address - Street 1:1473 E G ST
Practice Address - Street 2:STE C
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-4205
Practice Address - Country:US
Practice Address - Phone:209-848-8074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54111122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist