Provider Demographics
NPI:1114098720
Name:EVELETH DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:EVELETH DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:EPP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-744-5440
Mailing Address - Street 1:320 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:EVELETH
Mailing Address - State:MN
Mailing Address - Zip Code:55734-1524
Mailing Address - Country:US
Mailing Address - Phone:218-744-5440
Mailing Address - Fax:218-744-5441
Practice Address - Street 1:320 GRANT AVE
Practice Address - Street 2:
Practice Address - City:EVELETH
Practice Address - State:MN
Practice Address - Zip Code:55734-1524
Practice Address - Country:US
Practice Address - Phone:218-744-5440
Practice Address - Fax:218-744-5441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty