Basic Information
| Provider Information | |||||||||
| NPI: | 1699069757 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIRSCH | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEMMON | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DENTAL STUDENT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 201 W 8TH ST | ||||||||
| Address2: | SUITE 810 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810033038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195624447 | ||||||||
| FaxNumber: | 7195831801 | ||||||||
| Practice Location | |||||||||
| Address1: | 18 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | GREENCASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656538615 | ||||||||
| FaxNumber: | 7656535227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2011 | ||||||||
| LastUpdateDate: | 05/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 12011627A | IN | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 12011627A | 01 | IN | INDIANA DENTAL LICENSE NO. 12011627A | OTHER |