Provider Demographics
NPI:1235597477
Name:RIDGE, EVAN
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:RIDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 WALNUT ST STE 1302
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-2908
Mailing Address - Country:US
Mailing Address - Phone:215-568-6222
Mailing Address - Fax:
Practice Address - Street 1:1601 WALNUT ST STE 1302
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-2908
Practice Address - Country:US
Practice Address - Phone:215-568-6222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PADS041185122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program