Healthcare Provider Details

I. General information

NPI: 1275909863
Provider Name (Legal Business Name): EDWARD E EVANS JR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2015
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LANDSTUL DENTAL ACTIVITY BLDG 3703 KIRCHBERG KASERNE
LANDSTUHL RP
66849
DE

IV. Provider business mailing address

USA DENTAC LANDSTUHL CMR 402
APO AE
09180
US

V. Phone/Fax

Practice location:
  • Phone: 0114963719464
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9501074-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: