Healthcare Provider Details

I. General information

NPI: 1063854339
Provider Name (Legal Business Name): LISA MCEVOY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2013
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 E TAMPA ST
SPRINGFIELD MO
65806
US

IV. Provider business mailing address

600 CAISSON HILL RD
FORT RILEY KS
66442-7037
US

V. Phone/Fax

Practice location:
  • Phone: 417-851-1589
  • Fax: 417-865-3479
Mailing address:
  • Phone: 785-239-7241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number00202031
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: