Provider Demographics
NPI:1003356973
Name:KLUTH FAMILY DENTISTRY,INC
Entity Type:Organization
Organization Name:KLUTH FAMILY DENTISTRY,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-770-1050
Mailing Address - Street 1:16000 PROSPERITY DR STE 400
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-4322
Mailing Address - Country:US
Mailing Address - Phone:317-770-1050
Mailing Address - Fax:317-770-1645
Practice Address - Street 1:16000 PROSPERITY DR STE 400
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-4322
Practice Address - Country:US
Practice Address - Phone:317-770-1050
Practice Address - Fax:317-770-1645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-27
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009126122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100173090AMedicaid
IN7582780001Medicare PIN
IN100173090AMedicaid
IN7582780001Medicare NSC
IN7582780002Medicare PIN