Provider Demographics
NPI:1942220496
Name:ADOLPH, KATHLEEN (DDS)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:ADOLPH
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 1:1801 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-3942
Mailing Address - Country:US
Mailing Address - Phone:918-756-4333
Mailing Address - Fax:918-759-2081
Practice Address - Street 1:800 W FORREST AVE
Practice Address - Street 2:
Practice Address - City:EUFAULA
Practice Address - State:OK
Practice Address - Zip Code:74432-3249
Practice Address - Country:US
Practice Address - Phone:918-689-2547
Practice Address - Fax:918-689-3643
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4960122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist