Healthcare Provider Details

I. General information

NPI: 1649920109
Provider Name (Legal Business Name): BRANDON V EVERT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 09/15/2023
Certification Date: 09/13/2023
Deactivation Date: 06/08/2022
Reactivation Date: 07/11/2022

III. Provider practice location address

674 BLVD DE FRANCE
BEAUFORT SC
29905
US

IV. Provider business mailing address

40W066 CHADSWORTH DR
GENEVA IL
60134-5414
US

V. Phone/Fax

Practice location:
  • Phone: 630-777-5222
  • Fax:
Mailing address:
  • Phone: 630-777-5222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.033714
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: