Provider Demographics
NPI:1699391953
Name:KUTANOVSKI, DEVON MARIE (DMD)
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:MARIE
Last Name:KUTANOVSKI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10010 WHITE JASMINE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-0580
Mailing Address - Country:US
Mailing Address - Phone:925-596-0220
Mailing Address - Fax:
Practice Address - Street 1:229 S EAST ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-4058
Practice Address - Country:US
Practice Address - Phone:219-356-0216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0326291223G0001X
IN12013425A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice