Provider Demographics
NPI:1265415996
Name:DEWALD, ERNEST JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:ERNEST
Middle Name:JAMES
Last Name:DEWALD
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 1:1301 PEACHERS MILL RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-4610
Mailing Address - Country:US
Mailing Address - Phone:931-572-9152
Mailing Address - Fax:931-572-9155
Practice Address - Street 1:1301 PEACHERS MILL RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-4610
Practice Address - Country:US
Practice Address - Phone:931-572-9152
Practice Address - Fax:931-572-9155
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS006850122300000X
MDMD06299122300000X
NY032522122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
719384OtherUNITED CONCORDIA
0174736OtherBCBS OF TN
0018148OtherDORAL