MEDICARE: DR. ERON J EVANS DDS

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	122300000X	Dentist	D3891	ID

General Provider Information

NPI Number	:	1386681427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERON J EVANS DDS

Provider Business Mailing Address
First Line	:	374 ROANOKE DR
Second Line	:
City	:	CHUBBUCK
State	:	ID
Zip	:	83202
Country	:	US
Telephone Number	:	208-238-1583
Fax Number	:

Provider Business Practice Location Address
First Line	:	390 S 3RD W
Second Line	:	MOUNTAIN VIEW DENTAL
City	:	SODA SPRINGS
State	:	ID
Zip	:	83276
Country	:	US
Telephone Number	:	208-547-2220
Fax Number	:	208-547-2224

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

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	07/08/2007

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