Healthcare Provider Details

I. General information

NPI: 1639480502
Provider Name (Legal Business Name): LUKE MICHAEL KEUSCH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 E CHESTNUT ST
CORYDON IN
47112-1203
US

IV. Provider business mailing address

439 E CHESTNUT ST
CORYDON IN
47112-1203
US

V. Phone/Fax

Practice location:
  • Phone: 812-630-0493
  • Fax:
Mailing address:
  • Phone: 812-738-2287
  • Fax: 812-738-2287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12011481A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12011481A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: