MEDICARE: HUNTSVILLE DENTAL PLLC

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	1223G0001X	General Practice Dentistry	23695	TX

General Provider Information

NPI Number	:	1518341767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HUNTSVILLE DENTAL PLLC

Provider Business Mailing Address
First Line	:	PO BOX 674330
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75267-4330
Country	:	US
Telephone Number	:	940-808-1970
Fax Number	:	855-731-5147

Provider Business Practice Location Address
First Line	:	3011 HIGHWAY 30 W
Second Line	:
City	:	HUNTSVILLE
State	:	TX
Zip	:	77340-3534
Country	:	US
Telephone Number	:	936-294-0400
Fax Number	:

Authorized Official
Title or Position	:	OWNER, DDS
Name	:	DR. EVERETT C EVANS
Credential	:	DDS
Telephone Number	:	940-808-1970

Provider Enumeration Date	:	07/17/2015
Last Update Date	:	07/17/2015

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