Healthcare Provider Details

I. General information

NPI: 1336709666
Provider Name (Legal Business Name): ERIC E BEWLEY CDT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2094 RICHARD ST
PRESCOTT AZ
86301-1047
US

IV. Provider business mailing address

2094 RICHARD ST
PRESCOTT AZ
86301-1047
US

V. Phone/Fax

Practice location:
  • Phone: 928-710-7212
  • Fax:
Mailing address:
  • Phone: 928-710-7212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126900000X
TaxonomyDental Laboratory Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: