Provider Demographics
NPI:1275190183
Name:SCHMIDT, EVAN RANDALL (DDS,MSD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:RANDALL
Last Name:SCHMIDT
Suffix:
Gender:M
Credentials:DDS,MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 WILLOWCREEK RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-4424
Mailing Address - Country:US
Mailing Address - Phone:219-477-0089
Mailing Address - Fax:
Practice Address - Street 1:3110 WILLOWCREEK RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-4424
Practice Address - Country:US
Practice Address - Phone:219-477-0089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-27
Last Update Date:2019-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012798A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1223X0400XOtherORTHODONTICS
IN12012798AOtherINDIANA DENTAL LICENSE
IN1420-51-3376OtherDRIVERS LICENSE NUMBER