Provider Demographics
NPI:1043994908
Name:DEWAN, VIVEK KANWAL
Entity type:Individual
Prefix:
First Name:VIVEK
Middle Name:KANWAL
Last Name:DEWAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 PINE WARBLER PL UNIT 10114
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34240-1547
Mailing Address - Country:US
Mailing Address - Phone:704-891-9195
Mailing Address - Fax:
Practice Address - Street 1:385 UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34202
Practice Address - Country:US
Practice Address - Phone:941-405-3953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL000000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty