=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316114580
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALAN B. EVANS D.D.S., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2008
-----------------------------------------------------
Last Update Date | 05/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1612 PLAZA PL
-----------------------------------------------------
City | MUSCATINE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52761-5364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-264-1180
-----------------------------------------------------
Fax | 563-288-2776
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1612 PLAZA PL
-----------------------------------------------------
City | MUSCATINE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52761-5364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-264-1180
-----------------------------------------------------
Fax | 563-288-2776
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. ALAN BLAKE EVANS
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 563-264-1180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 07985
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------