Provider Demographics
NPI:1164025623
Name:JEFFREY R EVANKO DMD LLC
Entity Type:Organization
Organization Name:JEFFREY R EVANKO DMD LLC
Other - Org Name:EVANKO DENTAL GROUP OF MEDINA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:EVANKO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:330-725-6182
Mailing Address - Street 1:3637 MEDINA RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-8154
Mailing Address - Country:US
Mailing Address - Phone:330-725-6182
Mailing Address - Fax:
Practice Address - Street 1:3637 MEDINA RD STE 200
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-8154
Practice Address - Country:US
Practice Address - Phone:330-725-6182
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-18
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty