Provider Demographics
NPI:1043203235
Name:EVANSVILLE DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:EVANSVILLE DENTAL ASSOCIATES
Other - Org Name:TRISTATE FAMILY DNETAL CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-425-4206
Mailing Address - Street 1:800 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-1938
Mailing Address - Country:US
Mailing Address - Phone:812-425-4206
Mailing Address - Fax:812-423-4466
Practice Address - Street 1:800 1ST AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1938
Practice Address - Country:US
Practice Address - Phone:812-425-4206
Practice Address - Fax:812-423-4466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN54000097A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty