Provider Demographics
NPI:1508946435
Name:BULLER, EVAN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:M
Last Name:BULLER
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 1:510 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114
Mailing Address - Country:US
Mailing Address - Phone:216-621-3675
Mailing Address - Fax:216-621-9790
Practice Address - Street 1:510 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114
Practice Address - Country:US
Practice Address - Phone:216-621-3675
Practice Address - Fax:216-621-9790
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300188201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0782532Medicaid