Healthcare Provider Details

I. General information

NPI: 1518667005
Provider Name (Legal Business Name): CLARINDA FAMILY DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E WASHINGTON ST
CLARINDA IA
51632-1611
US

IV. Provider business mailing address

104 E WASHINGTON ST
CLARINDA IA
51632-1611
US

V. Phone/Fax

Practice location:
  • Phone: 712-542-5196
  • Fax:
Mailing address:
  • Phone: 712-542-5196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ANTHONY D EWIGMAN
Title or Position: PRINCIPAL
Credential: DDS
Phone: 712-542-5196