Provider Demographics
NPI:1053653139
Name:KNUST, KEVIN M (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:KNUST
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5138 LAKESHORE RD
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3115
Mailing Address - Country:US
Mailing Address - Phone:810-531-1193
Mailing Address - Fax:
Practice Address - Street 1:3009 E 92ND ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-4502
Practice Address - Country:US
Practice Address - Phone:773-978-1231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029750122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist