Provider Demographics
NPI:1053648055
Name:HEWITT DENTAL GROUP OF ELKHART, LTD.
Entity Type:Organization
Organization Name:HEWITT DENTAL GROUP OF ELKHART, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:HEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-532-3085
Mailing Address - Street 1:PO BOX 806
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-0806
Mailing Address - Country:US
Mailing Address - Phone:574-229-8180
Mailing Address - Fax:
Practice Address - Street 1:319 W LUSHER AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-1866
Practice Address - Country:US
Practice Address - Phone:574-389-8300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007801A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100222340Medicaid