Provider Demographics
NPI:1437497047
Name:GRODIN, EVAN DANIEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:DANIEL
Last Name:GRODIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 JUNIPER ST NE APT 707
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-7659
Mailing Address - Country:US
Mailing Address - Phone:770-851-8383
Mailing Address - Fax:
Practice Address - Street 1:3280 HOWELL MILL RD NW STE 327
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-4109
Practice Address - Country:US
Practice Address - Phone:470-451-0981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0143351223P0300X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223P0300XDental ProvidersDentistPeriodontics