Provider Demographics
NPI:1871294306
Name:SLATER, ETHAN W
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:W
Last Name:SLATER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MISSILE AVE
Mailing Address - Street 2:
Mailing Address - City:MINOT AFB
Mailing Address - State:ND
Mailing Address - Zip Code:58705-5003
Mailing Address - Country:US
Mailing Address - Phone:719-231-8122
Mailing Address - Fax:
Practice Address - Street 1:10 MISSILE AVE
Practice Address - Street 2:
Practice Address - City:MINOT AFB
Practice Address - State:ND
Practice Address - Zip Code:58705-5003
Practice Address - Country:US
Practice Address - Phone:719-333-5192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002056301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice