Healthcare Provider Details

I. General information

NPI: 1912746439
Provider Name (Legal Business Name): KUTANOVSKI DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 S EAST ST
CROWN POINT IN
46307-4058
US

IV. Provider business mailing address

229 S EAST ST
CROWN POINT IN
46307-4058
US

V. Phone/Fax

Practice location:
  • Phone: 219-356-0216
  • Fax: 219-356-0217
Mailing address:
  • Phone: 219-356-0216
  • Fax: 219-356-0217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. DEVON M KUTANOVSKI
Title or Position: OWNER DENTIST
Credential: DMD
Phone: 925-596-0220