Provider Demographics
NPI:1679721872
Name:DURHAM, KATHLEEN MARIE (DMD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MARIE
Last Name:DURHAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 E ORANGE RD
Mailing Address - Street 2:PO BOX 8015
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-9014
Mailing Address - Country:US
Mailing Address - Phone:319-296-1030
Mailing Address - Fax:319-296-4450
Practice Address - Street 1:1501 E ORANGE RD
Practice Address - Street 2:GRUNDY HALL, ROOM 152
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-9014
Practice Address - Country:US
Practice Address - Phone:319-296-1030
Practice Address - Fax:319-296-4450
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA08379122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist