Healthcare Provider Details

I. General information

NPI: 1891949590
Provider Name (Legal Business Name): JEREMY DAVID BEWLEY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2008
Last Update Date: 11/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 CRUME RD
VINE GROVE KY
40175-1130
US

IV. Provider business mailing address

848 ASHLAND ST
WEST LAFAYETTE IN
47906-1508
US

V. Phone/Fax

Practice location:
  • Phone: 270-877-5050
  • Fax:
Mailing address:
  • Phone: 765-838-2160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8511
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12011043A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: