MEDICARE: DR. BRIAN DAVID EVANS DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	61230	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GA1863	OTHER		GENERAL ANESTHESIA PERMIT
2	61230	OTHER	CA	DENTAL LICENSE

General Provider Information

NPI Number	:	1114229317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN DAVID EVANS DMD

Provider Business Mailing Address
First Line	:	4796 PANORAMA DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92116-1239
Country	:	US
Telephone Number	:	208-757-0787
Fax Number	:

Provider Business Practice Location Address
First Line	:	USS CARL VINSON CVN70
Second Line	:	UNIT 1000111 BOX 1770
City	:	FPO
State	:	AP
Zip	:	96629
Country	:	US
Telephone Number	:	619-545-4814
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2010
Last Update Date	:	03/07/2023

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