Provider Demographics
NPI:1780910240
Name:HOLSWORTH, KATHERINE JONES
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:JONES
Last Name:HOLSWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHERINE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:304 W ANTOINE ST
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7040 MCKAY RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-9261
Practice Address - Country:US
Practice Address - Phone:517-740-5620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902015485124Q00000X
TN4877124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist