Provider Demographics
NPI:1972504371
Name:LUETHKE, LARRY D (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:D
Last Name:LUETHKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 W SEVIER AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3799
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 W SEVIER AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3799
Practice Address - Country:US
Practice Address - Phone:423-224-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS50011223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1518969229OtherORGANIZATION NPI
TN1609878388OtherORGANIZATION NPI
TN3726194OtherGROUP MEDICARE NUMBER
TN1972504389OtherGROUP NPI NUMBER
TN1972504389OtherGROUP NPI NUMBER
TN3726194OtherGROUP MEDICARE NUMBER