Provider Demographics
NPI:1669966198
Name:EWOLDT, EMILY MARTIN (DMD)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:MARTIN
Last Name:EWOLDT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 FOLGER ST
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-1304
Mailing Address - Country:US
Mailing Address - Phone:864-650-0090
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:2018-06-18
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC91471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice