Provider Demographics
NPI:1962614875
Name:DEWITT, MARK LAWRENCE (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LAWRENCE
Last Name:DEWITT
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 1:5001 W ST JOE HWY
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-4023
Mailing Address - Country:US
Mailing Address - Phone:517-323-7926
Mailing Address - Fax:517-323-8986
Practice Address - Street 1:5001 W ST JOE HWY
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-4023
Practice Address - Country:US
Practice Address - Phone:517-323-7926
Practice Address - Fax:517-323-8986
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI9010133261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice