Provider Demographics
NPI:1720148984
Name:WOOLUM, KERRY L (DMD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:L
Last Name:WOOLUM
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 1:121 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40977
Mailing Address - Country:US
Mailing Address - Phone:606-337-3034
Mailing Address - Fax:606-337-5305
Practice Address - Street 1:121 W VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977-1600
Practice Address - Country:US
Practice Address - Phone:606-337-3034
Practice Address - Fax:606-337-5305
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4864122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60048642Medicaid
KY60048642Medicaid