Healthcare Provider Details

I. General information

NPI: 1497836571
Provider Name (Legal Business Name): ROBERT PHILIP KOUTNIK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N 7TH ST
REEDSVILLE WI
54230-0190
US

IV. Provider business mailing address

115 N 7TH ST P.O. BOX 190
REEDSVILLE WI
54230-0190
US

V. Phone/Fax

Practice location:
  • Phone: 920-754-4014
  • Fax: 920-754-4014
Mailing address:
  • Phone: 920-754-4014
  • Fax: 920-754-4014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2356
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: