Provider Demographics
NPI:1154072577
Name:KLUTCHARCH, KRISTIN NICOLE (DMD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:NICOLE
Last Name:KLUTCHARCH
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 1:5301 W 108TH PL
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-5051
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5301 W 108TH PL
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5051
Practice Address - Country:US
Practice Address - Phone:708-372-4094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-17
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.033751122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program