Provider Demographics
NPI:1225454556
Name:DEWITT, GARY VAN
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:VAN
Last Name:DEWITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 PETERMAN DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3432
Mailing Address - Country:US
Mailing Address - Phone:318-443-0505
Mailing Address - Fax:
Practice Address - Street 1:1400 PETERMAN DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3432
Practice Address - Country:US
Practice Address - Phone:318-443-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3271122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist