Provider Demographics
NPI:1326185893
Name:SPIVACK, EVAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:SPIVACK
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 1:911 ALPINE DR
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-5542
Mailing Address - Country:US
Mailing Address - Phone:201-833-4246
Mailing Address - Fax:
Practice Address - Street 1:NJDS-UMDNJ
Practice Address - Street 2:110 BERGEN ST
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103
Practice Address - Country:US
Practice Address - Phone:973-972-7040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI 201131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice