Provider Demographics
NPI:1023171857
Name:KAUTZMAN, DENNIS J (OD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:J
Last Name:KAUTZMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3121 E VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-1404
Mailing Address - Country:US
Mailing Address - Phone:810-385-8152
Mailing Address - Fax:810-385-9638
Practice Address - Street 1:4460 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3809
Practice Address - Country:US
Practice Address - Phone:810-385-9638
Practice Address - Fax:810-385-8105
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002310152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU38490Medicare UPIN