Provider Demographics
NPI:1154549376
Name:COVARRUBIAS, EVANGELINA (DDS)
Entity type:Individual
Prefix:
First Name:EVANGELINA
Middle Name:
Last Name:COVARRUBIAS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 AWIXA AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8802
Mailing Address - Country:US
Mailing Address - Phone:631-666-8127
Mailing Address - Fax:
Practice Address - Street 1:781 SUFFOLK AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4409
Practice Address - Country:US
Practice Address - Phone:631-273-6315
Practice Address - Fax:631-273-0692
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042596-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBE898-1070OtherDEA #
NY113175290OtherTIN #