=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104815042
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARRY JAMES EVANS DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2005
-----------------------------------------------------
Last Update Date | 08/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2133 PEPPERRELL ST BLDG 3352
-----------------------------------------------------
City | JBSA LACKLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-292-8627
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13830 PALATINE HL
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78253-7004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-592-5805
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 17074
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------