Provider Demographics
NPI:1013523703
Name:AGNETTA, EVAN JAMES (DDS, MS)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:JAMES
Last Name:AGNETTA
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 IVES ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4216
Mailing Address - Country:US
Mailing Address - Phone:208-761-1210
Mailing Address - Fax:
Practice Address - Street 1:6311 KINGSTON PIKE STE 26W
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4900
Practice Address - Country:US
Practice Address - Phone:208-761-1210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000112861223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty