Healthcare Provider Details

I. General information

NPI: 1083691281
Provider Name (Legal Business Name): MARTIN E. EVERS JR. DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S WAKARA WAY
SLC UT
84108-1213
US

IV. Provider business mailing address

PSC 808 BOX 19
FPO AE
09618-0001
US

V. Phone/Fax

Practice location:
  • Phone: 843-812-8649
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number14224638-9926
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number051003
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14224638-9926
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number051003-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: