Provider Demographics
NPI:1972613339
Name:KIRTLEY & STUCKWISCH, LLC
Entity Type:Organization
Organization Name:KIRTLEY & STUCKWISCH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:KIRTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-522-1899
Mailing Address - Street 1:325 N WALNUT ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-2113
Mailing Address - Country:US
Mailing Address - Phone:812-522-1899
Mailing Address - Fax:812-522-2759
Practice Address - Street 1:325 N WALNUT ST
Practice Address - Street 2:SUITE A
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2113
Practice Address - Country:US
Practice Address - Phone:812-522-1899
Practice Address - Fax:812-522-2759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008976A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100140320Medicaid