Healthcare Provider Details

I. General information

NPI: 1659781888
Provider Name (Legal Business Name): EVAN R WARDIUS DMS, CAGS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 COCHITUATE RD STE 304
FRAMINGHAM MA
01701-4648
US

IV. Provider business mailing address

850 HARRISON AVE
BOSTON MA
02118-4001
US

V. Phone/Fax

Practice location:
  • Phone: 508-424-2525
  • Fax: 508-424-2528
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN1857883
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: