Healthcare Provider Details

I. General information

NPI: 1770700205
Provider Name (Legal Business Name): KEITH D KUTZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 TRUMAN ST
KIMBERLY WI
54136-2211
US

IV. Provider business mailing address

W5936 BLAZING STAR DR
APPLETON WI
54915-7418
US

V. Phone/Fax

Practice location:
  • Phone: 920-733-3339
  • Fax:
Mailing address:
  • Phone: 920-731-3363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2783-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: