Healthcare Provider Details

I. General information

NPI: 1275190183
Provider Name (Legal Business Name): EVAN RANDALL SCHMIDT DDS,MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2019
Last Update Date: 05/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 WILLOWCREEK RD
PORTAGE IN
46368-4424
US

IV. Provider business mailing address

3110 WILLOWCREEK RD
PORTAGE IN
46368-4424
US

V. Phone/Fax

Practice location:
  • Phone: 219-477-0089
  • Fax:
Mailing address:
  • Phone: 219-477-0089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12012798A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: