Healthcare Provider Details

I. General information

NPI: 1033106000
Provider Name (Legal Business Name): JONATHAN DAVID EVANS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JONATHAN DAVID EVANS DDS

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 08/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 FISHER ST
BILOXI MS
39534
US

IV. Provider business mailing address

52D MEDICAL GROUP UNIT 3865
APO AE
09126-3865
US

V. Phone/Fax

Practice location:
  • Phone: 228-376-0511
  • Fax:
Mailing address:
  • Phone: 496565913590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number19482
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: