Provider Demographics
NPI:1497051643
Name:EVAN M. DENTES, M.D., P.C.
Entity Type:Organization
Organization Name:EVAN M. DENTES, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DENTES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-457-7290
Mailing Address - Street 1:5100 W TAFT RD
Mailing Address - Street 2:SUITE 2Q
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3807
Mailing Address - Country:US
Mailing Address - Phone:315-457-7290
Mailing Address - Fax:315-451-1663
Practice Address - Street 1:5100 W TAFT RD
Practice Address - Street 2:SUITE 2Q
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3807
Practice Address - Country:US
Practice Address - Phone:315-457-7290
Practice Address - Fax:315-451-1663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-07
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131699-1208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00563497Medicaid
NYB82770Medicare UPIN