Provider Demographics
NPI:1770700205
Name:KUTZ, KEITH D (DDS)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:D
Last Name:KUTZ
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:W5936 BLAZING STAR DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-7418
Mailing Address - Country:US
Mailing Address - Phone:920-731-3363
Mailing Address - Fax:
Practice Address - Street 1:1020 TRUMAN ST
Practice Address - Street 2:
Practice Address - City:KIMBERLY
Practice Address - State:WI
Practice Address - Zip Code:54136-2211
Practice Address - Country:US
Practice Address - Phone:920-733-3339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2783-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist