=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447368915
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN K EVERSMAN DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 W MAIN ST SUITE 300
-----------------------------------------------------
City | VAN WERT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45891
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-238-1774
-----------------------------------------------------
Fax | 419-238-2110
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 W MAIN ST SUITE 300
-----------------------------------------------------
City | VAN WERT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45891
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-238-1774
-----------------------------------------------------
Fax | 419-238-2110
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES
-----------------------------------------------------
Name | DR. JOHN K EVERSMAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 419-238-1774
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 30013665
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------