Healthcare Provider Details

I. General information

NPI: 1780673202
Provider Name (Legal Business Name): RICHARD B EVANS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8530 LA MESA BLVD STE 204
LA MESA CA
91942-0966
US

IV. Provider business mailing address

8530 LA MESA BLVD STE 204
LA MESA CA
91942-0966
US

V. Phone/Fax

Practice location:
  • Phone: 619-494-2492
  • Fax: 619-460-0700
Mailing address:
  • Phone: 619-494-2492
  • Fax: 619-460-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number31914
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number31914
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number31914
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: