Provider Demographics
NPI:1629185269
Name:EWALT, JOHN W (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:EWALT
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 1:812 COSHOCTON AVE
Mailing Address - Street 2:4
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-1947
Mailing Address - Country:US
Mailing Address - Phone:740-393-2161
Mailing Address - Fax:
Practice Address - Street 1:812 COSHOCTON AVE
Practice Address - Street 2:4
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-1947
Practice Address - Country:US
Practice Address - Phone:740-393-2161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH122121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2613505Medicare ID - Type UnspecifiedPROVIDER NUMBER