Provider Demographics
NPI:1881024420
Name:CETTIE, EVAN (DDS)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:CETTIE
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 1:901 COLORADO BLVD APT 521
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-4089
Mailing Address - Country:US
Mailing Address - Phone:832-470-6344
Mailing Address - Fax:
Practice Address - Street 1:1200 S WADSWORTH BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80232-5473
Practice Address - Country:US
Practice Address - Phone:303-733-7533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002021101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice