MEDICARE: DR. EVAN J SHORT DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DEN.00202905	CO
2	1223G0001X	General Practice Dentistry	7023	AZ
3	1223G0001X	General Practice Dentistry	DEN.00202905	CO
4	122300000X	Dentist	019034032	IL

General Provider Information

NPI Number	:	1861558652
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVAN J SHORT DDS

Provider Business Mailing Address
First Line	:	3996 RED CEDAR DR UNIT A3
Second Line	:
City	:	HIGHLANDS RANCH
State	:	CO
Zip	:	80126-8066
Country	:	US
Telephone Number	:	303-470-9696
Fax Number	:	216-584-1364

Provider Business Practice Location Address
First Line	:	760 BELOIT RD
Second Line	:
City	:	BELVIDERE
State	:	IL
Zip	:	61008-1745
Country	:	US
Telephone Number	:	815-547-5151
Fax Number	:	815-547-5336

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	01/10/2024

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