Healthcare Provider Details

I. General information

NPI: 1376819029
Provider Name (Legal Business Name): DEWITT DENTAL PROFESSIONALS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 W MAIN ST
YORKTOWN TX
78164-5127
US

IV. Provider business mailing address

PO BOX 590
CUERO TX
77954-0590
US

V. Phone/Fax

Practice location:
  • Phone: 361-564-2239
  • Fax:
Mailing address:
  • Phone: 361-564-2239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22869
License Number StateTX

VIII. Authorized Official

Name: DR. KIMBERLY MARIE KOENIG
Title or Position: MANAGING MEMBER
Credential: D.D.S.
Phone: 361-243-6242