Healthcare Provider Details

I. General information

NPI: 1043062177
Provider Name (Legal Business Name): ALYSSA EVANS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 ALBANY ST
BOSTON MA
02118-3550
US

IV. Provider business mailing address

7A HALF MOON ST
BOSTON MA
02125-4915
US

V. Phone/Fax

Practice location:
  • Phone: 617-358-3466
  • Fax:
Mailing address:
  • Phone: 586-216-6436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN10000287
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: