Healthcare Provider Details

I. General information

NPI: 1750476099
Provider Name (Legal Business Name): TIMOTHY WALTER KUTAS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 12/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 N HIGHLAND ST
MEMPHIS TN
38122-4521
US

IV. Provider business mailing address

519 N HIGHLAND ST
MEMPHIS TN
38122-4521
US

V. Phone/Fax

Practice location:
  • Phone: 901-327-5604
  • Fax:
Mailing address:
  • Phone: 901-327-5604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS7087
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: