Provider Demographics
NPI:1497378137
Name:TITOV, EVGENY
Entity Type:Individual
Prefix:
First Name:EVGENY
Middle Name:
Last Name:TITOV
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 1:6654 COLLIER BLVD UNIT 104
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34114-8179
Mailing Address - Country:US
Mailing Address - Phone:352-727-2172
Mailing Address - Fax:
Practice Address - Street 1:6654 COLLIER BLVD UNIT 104
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34114-8179
Practice Address - Country:US
Practice Address - Phone:239-331-3575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-28
Last Update Date:2021-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR44321223G0001X
FL24874122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice