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General NPI Number Information
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NPI Number | 1538142492
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Entity Type | Individual
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Provider Name | GLENN JEFFREY EVANS D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 11/23/2005
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Last Update Date | 06/29/2012
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Provider Practice Location Address
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Address Line | 703 PARKWAY DR
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City | WHEATON
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State | IL
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Zip | 60187-3646
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Country | US
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Telephone | 630-362-8674
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Fax | 630-752-9588
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Provider Business Mailing Address
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Address Line | 703 PARKWAY DR
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City | WHEATON
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State | IL
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Zip | 60187-3646
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Country | US
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Telephone | 630-362-8674
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Fax | 630-752-9588
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019026423
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License Number State | IL
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