Provider Demographics
NPI:1558091819
Name:TWEET, AUSTIN (DDS)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:TWEET
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 RIDGE AVE APT C404
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-6232
Mailing Address - Country:US
Mailing Address - Phone:701-400-0573
Mailing Address - Fax:
Practice Address - Street 1:600 DAKOTA ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-3742
Practice Address - Country:US
Practice Address - Phone:815-459-1214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0337491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice