Healthcare Provider Details

I. General information

NPI: 1497048664
Provider Name (Legal Business Name): RICHARD B. EVANS, D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2011
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
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: 619-460-0700
  • Fax: 619-460-0707
Mailing address:
  • Phone: 619-494-2492
  • Fax: 619-460-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number31914
License Number StateCA

VIII. Authorized Official

Name: DR. RICHARD B. EVANS
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 760-468-1828