=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215396809
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR JAIME V. EVANGELISTA JR., DMD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2016
-----------------------------------------------------
Last Update Date | 02/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24901 SANTA CLARA ST # B2
-----------------------------------------------------
City | HAYWARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94544-2147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-887-6835
-----------------------------------------------------
Fax | 510-887-2872
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24901 SANTA CLARA ST # B2
-----------------------------------------------------
City | HAYWARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94544-2147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-887-6835
-----------------------------------------------------
Fax | 510-887-2872
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. JAIME V EVANGELISTA JR.
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 510-887-6835
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 37103
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------