Provider Demographics
NPI:1053402198
Name:KLUTH FAMILY DENTISTRY INC.
Entity type:Organization
Organization Name:KLUTH FAMILY DENTISTRY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIZELOVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-724-7729
Mailing Address - Street 1:2204 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:IN
Mailing Address - Zip Code:46001-8059
Mailing Address - Country:US
Mailing Address - Phone:765-724-7729
Mailing Address - Fax:765-724-9519
Practice Address - Street 1:2204 S PARK AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:IN
Practice Address - Zip Code:46001-8059
Practice Address - Country:US
Practice Address - Phone:765-724-7729
Practice Address - Fax:765-724-9519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120091261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000089901OtherANTHEM BLUE CROSS
IN784991OtherMILITARY
IN000000189293OtherANTHEM BLUE CROSS BLUE SH
IL9177506Medicaid
IN000000189293OtherANTHEM BLUE CROSS BLUE SH