Healthcare Provider Details

I. General information

NPI: 1487632766
Provider Name (Legal Business Name): DAVID LEIGH EVANS D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10520 PARK RD SUITE 102
CHARLOTTE NC
28210-8487
US

IV. Provider business mailing address

10520 PARK RD SUITE 102
CHARLOTTE NC
28210-8487
US

V. Phone/Fax

Practice location:
  • Phone: 704-341-0448
  • Fax: 704-341-0683
Mailing address:
  • Phone: 704-341-0448
  • Fax: 704-341-0683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3916
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: