Healthcare Provider Details

I. General information

NPI: 1699391953
Provider Name (Legal Business Name): DEVON MARIE KUTANOVSKI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2020
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

10010 WHITE JASMINE DR
SAINT JOHN IN
46373-0580
US

V. Phone/Fax

Practice location:
  • Phone: 219-356-0216
  • Fax:
Mailing address:
  • Phone: 925-596-0220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.032629
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12013425A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: