Provider Demographics
NPI:1578940409
Name:LARRY D ROTHENBERGER, INC
Entity Type:Organization
Organization Name:LARRY D ROTHENBERGER, INC
Other - Org Name:AETHETICS AND FAMILY DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE MANAGER/DENTAL HYGIENIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:LDH
Authorized Official - Phone:765-659-3351
Mailing Address - Street 1:1253 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IN
Mailing Address - Zip Code:46041-3312
Mailing Address - Country:US
Mailing Address - Phone:765-659-3351
Mailing Address - Fax:765-659-9037
Practice Address - Street 1:1253 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041-3312
Practice Address - Country:US
Practice Address - Phone:765-659-3351
Practice Address - Fax:765-659-9037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007174A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100082810AMedicaid