Provider Demographics
NPI:1811039084
Name:KNUTSON, JOHN EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:KNUTSON
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 1:190 GARDNER AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-2160
Mailing Address - Country:US
Mailing Address - Phone:262-763-3012
Mailing Address - Fax:262-763-4588
Practice Address - Street 1:190 GARDNER AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-2160
Practice Address - Country:US
Practice Address - Phone:262-763-3012
Practice Address - Fax:262-763-4588
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5687-0151223G0001X
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice