Provider Demographics
NPI:1164594040
Name:EVANKO, WILLIAM A (DDS)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:EVANKO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 E. WASHINTON ST. #402
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3332
Mailing Address - Country:US
Mailing Address - Phone:330-725-8449
Mailing Address - Fax:330-722-1805
Practice Address - Street 1:970 E. WASHINTON ST. #402
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3332
Practice Address - Country:US
Practice Address - Phone:330-725-8449
Practice Address - Fax:330-722-1805
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0138771223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9251381Medicare ID - Type Unspecified