Healthcare Provider Details

I. General information

NPI: 1356316202
Provider Name (Legal Business Name): LARRY D EVANS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 S 4TH ST SUITE 240
LEAVENWORTH KS
66048-5071
US

IV. Provider business mailing address

3550 S 4TH ST SUITE 240
LEAVENWORTH KS
66048-5071
US

V. Phone/Fax

Practice location:
  • Phone: 913-772-4334
  • Fax: 913-772-0851
Mailing address:
  • Phone: 913-772-4334
  • Fax: 913-772-0851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number4672
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: