Provider Demographics
NPI:1891192415
Name:MI DENTISTA LLC
Entity Type:Organization
Organization Name:MI DENTISTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:KUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-658-4600
Mailing Address - Street 1:4801 COTTAGE GROVE RD STE D
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716-1349
Mailing Address - Country:US
Mailing Address - Phone:608-658-4600
Mailing Address - Fax:
Practice Address - Street 1:4801 COTTAGE GROVE RD STE D
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716-1349
Practice Address - Country:US
Practice Address - Phone:608-658-4600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5729-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty