Provider Demographics
NPI:1114441755
Name:FUSION DENTAL- HEWITT PLLC
Entity Type:Organization
Organization Name:FUSION DENTAL- HEWITT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFCOAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-799-4867
Mailing Address - Street 1:121 EASTGATE PLZ
Mailing Address - Street 2:
Mailing Address - City:BELLMEAD
Mailing Address - State:TX
Mailing Address - Zip Code:76705-2868
Mailing Address - Country:US
Mailing Address - Phone:254-799-4867
Mailing Address - Fax:254-799-4872
Practice Address - Street 1:1605 HEWITT DR.
Practice Address - Street 2:SUITE 102
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712
Practice Address - Country:US
Practice Address - Phone:254-799-4867
Practice Address - Fax:254-799-4872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-26
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27552261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX288519603Medicaid