Provider Demographics
NPI:1154546489
Name:BEACHE, KATHLEEN JUDITH (DDS)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:JUDITH
Last Name:BEACHE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6510 FALL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-5087
Mailing Address - Country:US
Mailing Address - Phone:317-259-9426
Mailing Address - Fax:317-259-9426
Practice Address - Street 1:7225 US 31 S STE G
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-8599
Practice Address - Country:US
Practice Address - Phone:317-496-6652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009653A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200097410Medicaid
IN12009653AOtherINDIANA PROFESSIONAL LICENSING AGENCY