Healthcare Provider Details

I. General information

NPI: 1538375241
Provider Name (Legal Business Name): JUSTIN E. EVANSON MD, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 LOCUST ST
DENVER CO
80220-1634
US

IV. Provider business mailing address

1960 LOCUST ST
DENVER CO
80220-1634
US

V. Phone/Fax

Practice location:
  • Phone: 214-957-4765
  • Fax:
Mailing address:
  • Phone: 214-957-4765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number50194
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: