=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154549376
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVANGELINA COVARRUBIAS DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2007
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 781 SUFFOLK AVE SUITE 3
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11717-4409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-273-6315
-----------------------------------------------------
Fax | 631-273-0692
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18 AWIXA AVE
-----------------------------------------------------
City | BAY SHORE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11706-8802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-666-8127
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 042596-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------