Provider Demographics
NPI:1770103616
Name:TATFORD, EVAN SHELBY
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:SHELBY
Last Name:TATFORD
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 1:185 S BEADLE RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-4287
Mailing Address - Country:US
Mailing Address - Phone:337-234-2349
Mailing Address - Fax:
Practice Address - Street 1:185 S BEADLE RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-4287
Practice Address - Country:US
Practice Address - Phone:337-234-2349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA70851223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program