Healthcare Provider Details

I. General information

NPI: 1770103616
Provider Name (Legal Business Name): EVAN SHELBY TATFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 S BEADLE RD
LAFAYETTE LA
70508-4287
US

IV. Provider business mailing address

185 S BEADLE RD
LAFAYETTE LA
70508-4287
US

V. Phone/Fax

Practice location:
  • Phone: 337-234-2349
  • Fax:
Mailing address:
  • Phone: 337-234-2349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7085
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: