Provider Demographics
NPI:1689249567
Name:PIVETZ, EVAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:PIVETZ
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 1:922 CHATHAM LN UNIT C
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-2435
Mailing Address - Country:US
Mailing Address - Phone:614-743-1955
Mailing Address - Fax:
Practice Address - Street 1:3400 W 16TH ST STE 8E
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6862
Practice Address - Country:US
Practice Address - Phone:970-352-5448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002047071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty