Healthcare Provider Details

I. General information

NPI: 1548720873
Provider Name (Legal Business Name): MIA KUTNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 CENTRAL PARK AVE STE 207
SCARSDALE NY
10583-3250
US

IV. Provider business mailing address

9365 RIVIERA HILLS DR
GREENWOOD VILLAGE CO
80111-3453
US

V. Phone/Fax

Practice location:
  • Phone: 914-472-5252
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number063256
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: