Provider Demographics
NPI:1598891780
Name:KLUFAS, LYDIA ANN (DDS)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:ANN
Last Name:KLUFAS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-6919
Mailing Address - Country:US
Mailing Address - Phone:401-725-3707
Mailing Address - Fax:
Practice Address - Street 1:525 BROAD ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-6919
Practice Address - Country:US
Practice Address - Phone:401-725-3707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI2202122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RILK03955Medicaid