Healthcare Provider Details

I. General information

NPI: 1326155193
Provider Name (Legal Business Name): KEARY ALLEN BEWICK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5019 CENTRAL AVE
LAKE STATION IN
46405-2522
US

IV. Provider business mailing address

5019 CENTRAL AVE
LAKE STATION IN
46405-2522
US

V. Phone/Fax

Practice location:
  • Phone: 219-962-4200
  • Fax: 219-962-3149
Mailing address:
  • Phone: 219-962-4200
  • Fax: 219-962-3149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberIN8247
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: