Healthcare Provider Details

I. General information

NPI: 1134489198
Provider Name (Legal Business Name): CHRIS DAVID KUTANOVSKI D.D.S, M.S.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2012
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8782 MADISON AVE
INDIANAPOLIS IN
46227-7202
US

IV. Provider business mailing address

8782 MADISON AVE
INDIANAPOLIS IN
46227-7202
US

V. Phone/Fax

Practice location:
  • Phone: 317-882-2882
  • Fax:
Mailing address:
  • Phone: 219-613-3846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12011791A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: