Provider Demographics
NPI:1912042078
Name:WORTHAM, WILLIAM BRENT (DMD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:BRENT
Last Name:WORTHAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3239
Mailing Address - Country:US
Mailing Address - Phone:270-444-7645
Mailing Address - Fax:
Practice Address - Street 1:2107 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3239
Practice Address - Country:US
Practice Address - Phone:270-444-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY53021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice