Provider Demographics
NPI:1851672737
Name:SEVERE, EVODIE (DENTAL HYGIENIST)
Entity Type:Individual
Prefix:MS
First Name:EVODIE
Middle Name:
Last Name:SEVERE
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MADISON AVE
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-1600
Mailing Address - Country:US
Mailing Address - Phone:212-545-2439
Mailing Address - Fax:646-312-0481
Practice Address - Street 1:94-98 MANHATTAN AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-2505
Practice Address - Country:US
Practice Address - Phone:718-388-0390
Practice Address - Fax:718-486-5741
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02378124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid