Provider Demographics
NPI:1124766175
Name:EVANISH, EVAN JAMES (DMD)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:JAMES
Last Name:EVANISH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:PA
Mailing Address - Zip Code:18444-8624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 WYOMING AVE STE 300
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503-1238
Practice Address - Country:US
Practice Address - Phone:570-342-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-20
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PADS043637122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program