Healthcare Provider Details

I. General information

NPI: 1679612204
Provider Name (Legal Business Name): DR. MAYLANI EVANGELISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 80TH ST
KENOSHA WI
53142-4975
US

IV. Provider business mailing address

3410 80TH ST
KENOSHA WI
53142-4975
US

V. Phone/Fax

Practice location:
  • Phone: 262-697-0825
  • Fax: 262-697-0116
Mailing address:
  • Phone: 262-697-0825
  • Fax: 262-697-0116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number5469
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: