Provider Demographics
NPI:1659770493
Name:PRADO, EVAN MICHAEL (DMD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:MICHAEL
Last Name:PRADO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13301 N DALE MABRY HWY
Mailing Address - Street 2:SUITE D
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2400
Mailing Address - Country:US
Mailing Address - Phone:813-968-1373
Mailing Address - Fax:813-960-3560
Practice Address - Street 1:13301 N DALE MABRY HWY
Practice Address - Street 2:SUITE D
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2400
Practice Address - Country:US
Practice Address - Phone:813-968-1373
Practice Address - Fax:813-960-3560
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20896122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist