Healthcare Provider Details

I. General information

NPI: 1073835070
Provider Name (Legal Business Name): SCOTT R. EWERS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2010
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376 CLEAR LAKE RD
MANITOWISH WATERS WI
54545-9318
US

IV. Provider business mailing address

376 CLEAR LAKE RD
MANITOWISH WATERS WI
54545-9318
US

V. Phone/Fax

Practice location:
  • Phone: 715-543-2872
  • Fax:
Mailing address:
  • Phone: 715-543-2872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4001675-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: