Provider Demographics
NPI:1629135595
Name:EWERT, JOHN EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:EWERT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1573 154TH AVE NW
Mailing Address - Street 2:SUITE 107
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-2696
Mailing Address - Country:US
Mailing Address - Phone:763-786-3112
Mailing Address - Fax:763-786-3139
Practice Address - Street 1:1573 154TH AVE NW
Practice Address - Street 2:SUITE 107
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-2696
Practice Address - Country:US
Practice Address - Phone:763-786-3112
Practice Address - Fax:763-786-3139
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN82541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice