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General NPI Number Information
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NPI Number | 1407422421
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Entity Type | Individual
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Provider Name | EVAN JAMES FRY DMD
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Gender | Male
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Dates
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Enumeration Date | 06/01/2021
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Last Update Date | 01/31/2024
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Provider Practice Location Address
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Address Line | 4727 WILLOW SPRINGS RD STE 1N
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City | LA GRANGE
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State | IL
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Zip | 60525-6153
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Country | US
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Telephone | 708-352-7358
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Fax |
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Provider Business Mailing Address
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Address Line | 4727 WILLOW SPRINGS RD STE 1N
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City | LA GRANGE
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State | IL
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Zip | 60525-6153
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Country | US
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Telephone | 312-203-5930
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 319.022417
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019.033103
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License Number State | IL
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