Provider Demographics
NPI:1104054022
Name:FIEDLER, EVAN DEUTH (DDS)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:DEUTH
Last Name:FIEDLER
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 1:100 N MCCOY ST
Mailing Address - Street 2:P.O. BOX 597
Mailing Address - City:GRANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61326-9329
Mailing Address - Country:US
Mailing Address - Phone:815-339-6888
Mailing Address - Fax:815-339-6738
Practice Address - Street 1:100 N MCCOY ST
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61326-9329
Practice Address - Country:US
Practice Address - Phone:815-339-6888
Practice Address - Fax:815-339-6738
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190279371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice