MEDICARE: JACQUELINE EVANS RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	DH10640	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DH10640	OTHER	FL	LICENSE

General Provider Information

NPI Number	:	1255602660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE EVANS RDH

Provider Business Mailing Address
First Line	:	PO BOX 232
Second Line	:
City	:	DADE CITY
State	:	FL
Zip	:	33526-0232
Country	:	US
Telephone Number	:	352-518-2000
Fax Number	:	352-567-1974

Provider Business Practice Location Address
First Line	:	37944 CHURCH AVE
Second Line	:
City	:	DADE CITY
State	:	FL
Zip	:	33525-4207
Country	:	US
Telephone Number	:	352-518-2000
Fax Number	:	352-567-5193

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2012
Last Update Date	:	01/25/2026

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