MEDICARE: EVENLY SOUTHEAST, 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1730897240
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVENLY SOUTHEAST, PLLC

Provider Business Mailing Address
First Line	:	7250 WOODMONT AVE STE 330
Second Line	:
City	:	BETHESDA
State	:	MD
Zip	:	20814-3057
Country	:	US
Telephone Number	:	800-500-0493
Fax Number	:

Provider Business Practice Location Address
First Line	:	8223 W ATLANTIC BLVD
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33071-7450
Country	:	US
Telephone Number	:	800-500-0493
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED MEMBER/ORTHODONTIST
Name	:	DR. SHAUN SMITH
Credential	:	DDS
Telephone Number	:	240-394-0567

Provider Enumeration Date	:	11/14/2022
Last Update Date	:	11/14/2022

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