Provider Demographics
NPI:1194870626
Name:DEWITT DENTAL ASSOCIATES, PC
Entity type:Organization
Organization Name:DEWITT DENTAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-659-3411
Mailing Address - Street 1:907 11TH ST
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:IA
Mailing Address - Zip Code:52742-1207
Mailing Address - Country:US
Mailing Address - Phone:563-659-3411
Mailing Address - Fax:563-659-2831
Practice Address - Street 1:907 11TH ST
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:IA
Practice Address - Zip Code:52742-1207
Practice Address - Country:US
Practice Address - Phone:563-659-3411
Practice Address - Fax:563-659-2831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA074201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1283150Medicaid