Healthcare Provider Details

I. General information

NPI: 1457628562
Provider Name (Legal Business Name): KRM DENTAL L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2011
Last Update Date: 11/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 SANDERS CREEK PKWY
EAST SYRACUSE NY
13057-1307
US

IV. Provider business mailing address

9940 PENDLETON PIKE SUITE B
INDIANAPOLIS IN
46236-2823
US

V. Phone/Fax

Practice location:
  • Phone: 866-273-8204
  • Fax: 866-803-4943
Mailing address:
  • Phone: 317-541-1900
  • Fax: 317-897-8345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number11540
License Number StateIN

VIII. Authorized Official

Name: DR. KATIE REBECCA MCNUTT
Title or Position: OWNER
Credential: D.M.D
Phone: 317-547-1900