Provider Demographics
NPI:1518502152
Name:EWOLDT, NATHAN JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:JOHN
Last Name:EWOLDT
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 1:875 OLD CLEMSON HWY
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29672-8060
Mailing Address - Country:US
Mailing Address - Phone:864-654-5733
Mailing Address - Fax:
Practice Address - Street 1:875 OLD CLEMSON HWY
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-8060
Practice Address - Country:US
Practice Address - Phone:864-654-5733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9444122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist