Provider Demographics
NPI:1497892723
Name:VAGIANOS, EVANGELO (DDS)
Entity Type:Individual
Prefix:
First Name:EVANGELO
Middle Name:
Last Name:VAGIANOS
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 1:3535 RANDOLPH RD
Mailing Address - Street 2:SUITE 103-R
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1032
Mailing Address - Country:US
Mailing Address - Phone:704-365-0123
Mailing Address - Fax:704-364-8640
Practice Address - Street 1:3535 RANDOLPH RD
Practice Address - Street 2:SUITE 103-R
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1032
Practice Address - Country:US
Practice Address - Phone:704-365-0123
Practice Address - Fax:704-364-8640
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35121223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCT81592Medicare UPIN
NC241442BMedicare ID - Type Unspecified