Provider Demographics
NPI:1043552516
Name:PEDERSEN, EVAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 SW 46TH CT
Mailing Address - Street 2:APT 902
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-6264
Mailing Address - Country:US
Mailing Address - Phone:815-975-8758
Mailing Address - Fax:
Practice Address - Street 1:9401 SW HIGHWAY 200
Practice Address - Street 2:SUITE 101
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34481-9612
Practice Address - Country:US
Practice Address - Phone:352-873-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-22
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD200551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice