Healthcare Provider Details

I. General information

NPI: 1740201375
Provider Name (Legal Business Name): JOHN B WITTGEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N WEINBACH STE 910
EVANSVILLE IN
47711
US

IV. Provider business mailing address

701 N WEINBACH STE 910
EVANSVILLE IN
47711
US

V. Phone/Fax

Practice location:
  • Phone: 812-477-2836
  • Fax: 812-477-1011
Mailing address:
  • Phone: 812-477-2836
  • Fax: 812-477-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12006664A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: