Healthcare Provider Details

I. General information

NPI: 1952469652
Provider Name (Legal Business Name): JOSEPH CHARLES EVOLA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5650 MEXICO RD STE 5
SAINT PETERS MO
63376-1696
US

IV. Provider business mailing address

5650 MEXICO RD STE 5
SAINT PETERS MO
63376-1696
US

V. Phone/Fax

Practice location:
  • Phone: 636-447-6665
  • Fax:
Mailing address:
  • Phone: 248-477-3872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number14643
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2010022084
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: