Basic Information
| Provider Information | |||||||||
| NPI: | 1871723593 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IWEN | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 N 34TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548804477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153955380 | ||||||||
| FaxNumber: | 7153942682 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 TOWER AVE | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548805589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153945411 | ||||||||
| FaxNumber: | 7153925086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2009 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | GD42 | MN | N | Dental Providers | Dentist | General Practice | 1223G0001X | 6425-015 | WI | Y | Dental Providers | Dentist | General Practice |
No ID Information.