Provider Demographics
NPI:1477991552
Name:BLOSSOM, MARY CATHERINE (DMD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:CATHERINE
Last Name:BLOSSOM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:CATHERINE
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:233 WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:MS
Mailing Address - Zip Code:39117-3711
Mailing Address - Country:US
Mailing Address - Phone:601-732-6200
Mailing Address - Fax:601-732-6624
Practice Address - Street 1:233 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:MS
Practice Address - Zip Code:39117-3711
Practice Address - Country:US
Practice Address - Phone:601-732-6200
Practice Address - Fax:601-632-6624
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-11
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS369913122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist