Provider Demographics
NPI:1932818549
Name:LUTTRELL, INGRID DIEM THUY (RDH)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:DIEM THUY
Last Name:LUTTRELL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:GRAFENWOHR DENTAL ATTN: INGRID LUTTRELL
Mailing Address - Street 2:CMR 415 BOX 6544
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09114-0066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:GRAFENWOEHR DENTAL CLINIC
Practice Address - Street 2:BLDG 475
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09114
Practice Address - Country:US
Practice Address - Phone:496-371-9464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7023124Q00000X
GA43213124Q00000X
SC10852124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist