Provider Demographics
NPI:1457492878
Name:GARY V DEWITT DDS MS APC
Entity Type:Organization
Organization Name:GARY V DEWITT DDS MS APC
Other - Org Name:GARY V DEWITT DDS MS A PROFESSIONAL CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:DEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:318-443-0505
Mailing Address - Street 1:1400 PETERMAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301
Mailing Address - Country:US
Mailing Address - Phone:318-443-0505
Mailing Address - Fax:318-448-4751
Practice Address - Street 1:1400 PETERMAN DRIVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301
Practice Address - Country:US
Practice Address - Phone:318-443-0505
Practice Address - Fax:318-448-4751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3271122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty