Provider Demographics
NPI:1790071918
Name:KUTRUFF, KELLI A (DDS)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:A
Last Name:KUTRUFF
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:A
Other - Last Name:KUTRUFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:8920 SOUTHPOINTE DR
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-7509
Mailing Address - Country:US
Mailing Address - Phone:317-881-8161
Mailing Address - Fax:317-881-8151
Practice Address - Street 1:8920 SOUTHPOINTE DR
Practice Address - Street 2:SUITE A-1
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-7509
Practice Address - Country:US
Practice Address - Phone:317-881-8161
Practice Address - Fax:317-881-8151
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011647A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice