MEDICARE: DR. EVONNE EVANS DDS MS

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	4092	WI

General Provider Information

NPI Number	:	1194868802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVONNE EVANS DDS MS

Provider Business Mailing Address
First Line	:	2140 W SAINT PAUL AVE STE A
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53188-5905
Country	:	US
Telephone Number	:	262-547-2827
Fax Number	:	262-547-1269

Provider Business Practice Location Address
First Line	:	2140 W SAINT PAUL AVE STE A
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53188-5905
Country	:	US
Telephone Number	:	262-547-2827
Fax Number	:	262-547-1269

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

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	07/08/2007

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