MEDICARE: DR. MICHAEL BERRY MCEWAN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	10604	CO

General Provider Information

NPI Number	:	1568775666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL BERRY MCEWAN D.D.S.

Provider Business Mailing Address
First Line	:	243 MEADOW LN
Second Line	:
City	:	GLENWOOD SPRINGS
State	:	CO
Zip	:	81601-9223
Country	:	US
Telephone Number	:	541-892-2975
Fax Number	:

Provider Business Practice Location Address
First Line	:	1512 GRAND AVE
Second Line	:
City	:	GLENWOOD SPRINGS
State	:	CO
Zip	:	81601-3861
Country	:	US
Telephone Number	:	970-945-2588
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2010
Last Update Date	:	01/19/2012

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