Provider Demographics
NPI:1427518836
Name:WOODFORD, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:WOODFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-3155
Mailing Address - Country:US
Mailing Address - Phone:203-245-4266
Mailing Address - Fax:
Practice Address - Street 1:817 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-3155
Practice Address - Country:US
Practice Address - Phone:203-245-4266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT128511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice