Healthcare Provider Details

I. General information

NPI: 1275119661
Provider Name (Legal Business Name): EVAN KELTON DACKOWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 W RIO SALADO PKWY STE 101
TEMPE AZ
85281-2954
US

IV. Provider business mailing address

1215 W RIO SALADO PKWY STE 101
TEMPE AZ
85281-2954
US

V. Phone/Fax

Practice location:
  • Phone: 480-480-2020
  • Fax: 480-612-0150
Mailing address:
  • Phone: 480-480-2020
  • Fax: 480-612-0150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number81572
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: