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General NPI Number Information
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NPI Number | 1205114147
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Entity Type | Organization
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Legal Business Name | STATE STREET DENTISTRY PC
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Dates
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Enumeration Date | 07/26/2011
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Last Update Date | 07/26/2011
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Provider Practice Location Address
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Address Line | 333C STATE ST
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City | NEWBURGH
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State | IN
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Zip | 47630-1231
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Country | US
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Telephone | 812-853-3344
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Fax | 812-853-3370
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Provider Business Mailing Address
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Address Line | 333C STATE ST
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City | NEWBURGH
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State | IN
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Zip | 47630-1231
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Country | US
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Telephone | 812-853-3344
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Fax | 812-853-3370
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Authorized Official
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Title or Position | GENERAL MANAGER
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Name | MS. NATALIE MARIE KLUMP
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Credential |
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Telephone | 812-431-2201
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 12006732
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License Number State | IN
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