Healthcare Provider Details

I. General information

NPI: 1043203235
Provider Name (Legal Business Name): EVANSVILLE DENTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 1ST AVE
EVANSVILLE IN
47710-1938
US

IV. Provider business mailing address

800 1ST AVE
EVANSVILLE IN
47710-1938
US

V. Phone/Fax

Practice location:
  • Phone: 812-425-4206
  • Fax: 812-423-4466
Mailing address:
  • Phone: 812-425-4206
  • Fax: 812-423-4466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number54000097A
License Number StateIN

VIII. Authorized Official

Name: MARTHA FISHER
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 812-425-4206