Basic Information
| Provider Information | |||||||||
| NPI: | 1851672737 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEVERE | ||||||||
| FirstName: | EVODIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DENTAL HYGIENIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 MADISON AVE | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100101600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125452439 | ||||||||
| FaxNumber: | 6463120481 | ||||||||
| Practice Location | |||||||||
| Address1: | 94-98 MANHATTAN AVENUE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112062505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183880390 | ||||||||
| FaxNumber: | 7184865741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2011 | ||||||||
| LastUpdateDate: | 11/20/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 02378 | NY | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 00695941 | 05 | NY | MEDICAID |