Provider Demographics
NPI:1710955968
Name:HEWLETT, MARK THOMAS (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:HEWLETT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 PONTOON RD
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4015
Mailing Address - Country:US
Mailing Address - Phone:618-797-9877
Mailing Address - Fax:
Practice Address - Street 1:2101 PONTOON RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4015
Practice Address - Country:US
Practice Address - Phone:618-797-9877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-12
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice