Individual
ETHAN DUEWER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
1140 RICKARD RD STE 1, SPRINGFIELD, IL 62704-6385
(217) 787-3096
Mailing address
1140 RICKARD RD STE 1, SPRINGFIELD, IL 62704-6385
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
019.031206
IL
1223G0001X
General Practice Dentistry
019.031206
IL
Other
Enumeration date
06/20/2017
Last updated
01/18/2022
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