Provider Demographics
NPI:1639707623
Name:MAST, EVAN
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:MAST
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 1:302 FOXWOOD RD
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-7941
Mailing Address - Country:US
Mailing Address - Phone:908-418-8527
Mailing Address - Fax:
Practice Address - Street 1:105 ELMORA AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-1614
Practice Address - Country:US
Practice Address - Phone:908-402-0878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI028197001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program