Healthcare Provider Details

I. General information

NPI: 1508558768
Provider Name (Legal Business Name): EVAN LATHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2023
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 GOLFVIEW DR NE
ARAB AL
35016-5467
US

IV. Provider business mailing address

55 GOLFVIEW DR NE
ARAB AL
35016-5467
US

V. Phone/Fax

Practice location:
  • Phone: 256-586-8100
  • Fax:
Mailing address:
  • Phone: 256-586-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD.007661-C1
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: