Provider Demographics
NPI:1033568688
Name:EWELL, JUSTIN (DMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:EWELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 N BUTLER AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6429
Mailing Address - Country:US
Mailing Address - Phone:505-564-4470
Mailing Address - Fax:505-325-9707
Practice Address - Street 1:3501 N BUTLER AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6429
Practice Address - Country:US
Practice Address - Phone:505-564-4470
Practice Address - Fax:505-325-9707
Is Sole Proprietor?:No
Enumeration Date:2016-06-05
Last Update Date:2016-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD45181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice