Provider Demographics
NPI:1902923337
Name:TILLOTSON, EVAN CORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:CORY
Last Name:TILLOTSON
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 1:1711 N MURRAY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-1334
Mailing Address - Country:US
Mailing Address - Phone:719-596-3481
Mailing Address - Fax:719-596-9114
Practice Address - Street 1:1711 N MURRAY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-1334
Practice Address - Country:US
Practice Address - Phone:719-596-3481
Practice Address - Fax:719-596-9114
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO89831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice