Active NPI
Mary Kay Doersch, DDS
- Dentist
- Bluefield, WV
National Provider Identifier
1033220892
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 3246
- Practice address
- 1607 Maryland Ave
Bluefield, WV 24701 - Phone
- (304) 324-8703
- Fax
- (304) 324-8735
- NPI assigned
- Aug 31, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 3246 | WV | Primary |
Addresses
Primary practice location
1607 Maryland Ave
Bluefield, WV 24701
Mailing address
1607 Maryland Ave
Bluefield, WV 24701
Phone (304) 324-8703
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 4001019000 | Medicaid | WV |
Other names 1
- Mrs. Mary Kay Clack
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
- Opted out of Medicare
- Yes, effective Apr 16, 2015 through Apr 16, 2027
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Conklin & Doersch DDS Inc | Dentist | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156982400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1351036800000",
"number": "1033220892",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1607 MARYLAND AVE",
"city": "BLUEFIELD",
"state": "WV",
"postal_code": "24701",
"telephone_number": "304-324-8703",
"fax_number": "304-324-8735"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1607 MARYLAND AVE",
"city": "BLUEFIELD",
"state": "WV",
"postal_code": "24701",
"telephone_number": "304-324-8703",
"fax_number": "304-324-8735"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DOERSCH",
"first_name": "MARY",
"middle_name": "KAY",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-08-31",
"last_updated": "2012-10-24",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "WV",
"license": "3246",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "4001019000",
"state": "WV"
}
],
"endpoints": [],
"other_names": [
{
"first_name": "MARY",
"last_name": "CLACK",
"middle_name": "KAY",
"prefix": "MRS.",
"code": "5",
"type": "Other Name"
}
]
}Other providers in Bluefield, WV
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 24, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.