Provider Demographics
NPI:1508356197
Name:DAVYDOVA, EVELINA (DMD)
Entity Type:Individual
Prefix:
First Name:EVELINA
Middle Name:
Last Name:DAVYDOVA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10849 63RD AVE APT 1P
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1360
Mailing Address - Country:US
Mailing Address - Phone:347-702-3052
Mailing Address - Fax:
Practice Address - Street 1:119 W 57TH ST STE 512
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-2302
Practice Address - Country:US
Practice Address - Phone:347-702-3052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12612122300000X
NY390200000X
NY060590-01122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program