MEDICARE: JUSTIN C EWELL DMD PLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1447740584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUSTIN C EWELL DMD PLC

Provider Business Mailing Address
First Line	:	PO BOX 3189
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13220-3189
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7708 W BELL RD STE 103
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-8741
Country	:	US
Telephone Number	:	623-734-1506
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JUSTIN ELWELL
Credential	:
Telephone Number	:	623-734-1506

Provider Enumeration Date	:	05/15/2018
Last Update Date	:	05/15/2018

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