1154546489 NPI number — DR. KATHLEEN JUDITH BEACHE DDS

Table of content: DR. KATHLEEN JUDITH BEACHE DDS (NPI 1154546489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154546489 NPI number — DR. KATHLEEN JUDITH BEACHE DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEACHE
Provider First Name:
KATHLEEN
Provider Middle Name:
JUDITH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154546489
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6510 FALL CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46220-5087
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-259-9426
Provider Business Mailing Address Fax Number:
317-259-9426

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7225 US 31 S STE G
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46227-8599
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-496-6652
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  12009653A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200097410 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12009653A . This is a "INDIANA PROFESSIONAL LICENSING AGENCY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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