Provider Demographics
NPI:1083054720
Name:KEVIN G. WITT, DDS PLC
Entity Type:Organization
Organization Name:KEVIN G. WITT, DDS PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WITT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:319-530-2688
Mailing Address - Street 1:1355 ANTLER DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-2315
Mailing Address - Country:US
Mailing Address - Phone:319-530-2688
Mailing Address - Fax:
Practice Address - Street 1:1350 BOYSON RD
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:IA
Practice Address - Zip Code:52233-2211
Practice Address - Country:US
Practice Address - Phone:319-395-0159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-26
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0000338Medicaid