Provider Demographics
NPI:1386736742
Name:EVANS, TODD MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:MICHAEL
Last Name:EVANS
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 1:14634 SOARING HAWK TRL
Mailing Address - Street 2:
Mailing Address - City:HOAGLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46745-9613
Mailing Address - Country:US
Mailing Address - Phone:260-639-0602
Mailing Address - Fax:260-724-8552
Practice Address - Street 1:1020 SOUTHAMPTON DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-1049
Practice Address - Country:US
Practice Address - Phone:260-724-8015
Practice Address - Fax:260-724-8552
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009752122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist