Provider Demographics
NPI:1720094246
Name:EWIG, JON ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:ROBERT
Last Name:EWIG
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 1:3585 WENDLETON LN
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45432-2753
Mailing Address - Country:US
Mailing Address - Phone:937-426-8083
Mailing Address - Fax:937-426-2181
Practice Address - Street 1:3585 WENDLETON LN
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2753
Practice Address - Country:US
Practice Address - Phone:937-426-8083
Practice Address - Fax:937-426-2181
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH192771223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0854928Medicaid
OH0854928Medicaid
OHU29862Medicare UPIN