MEDICARE: DR. JOHN WILLIAM EVENSON 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	1223G0001X	General Practice Dentistry	11269	MN

General Provider Information

NPI Number	:	1902806094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN WILLIAM EVENSON DDS

Provider Business Mailing Address
First Line	:	PO BOX 821
Second Line	:
City	:	HOUSTON
State	:	MN
Zip	:	55943-0821
Country	:	US
Telephone Number	:	507-896-3976
Fax Number	:

Provider Business Practice Location Address
First Line	:	109 E MAPLE ST
Second Line	:
City	:	HOUSTON
State	:	MN
Zip	:	55943-8449
Country	:	US
Telephone Number	:	507-896-2202
Fax Number	:	507-896-3363

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

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	07/08/2007

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