Healthcare Provider Details

I. General information

NPI: 1891241196
Provider Name (Legal Business Name): MIKE HEWLETT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 M-62
CASSOPOLIS MI
49031
US

IV. Provider business mailing address

122 GRANT ST
NILES MI
49120-2281
US

V. Phone/Fax

Practice location:
  • Phone: 269-445-3874
  • Fax:
Mailing address:
  • Phone: 269-262-4364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901022012
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: