MEDICARE: DR. JOHN ROBERT 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	1223P0300X	Periodontics	6322	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	956705	OTHER	MD	UNITED CONCORDIA

General Provider Information

NPI Number	:	1972722700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN ROBERT EVANS DDS

Provider Business Mailing Address
First Line	:	3905 NATIONAL DR
Second Line	:	STE. 180
City	:	BURTONSVILLE
State	:	MD
Zip	:	20866-1100
Country	:	US
Telephone Number	:	301-421-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3905 NATIONAL DR
Second Line	:	STE. 180
City	:	BURTONSVILLE
State	:	MD
Zip	:	20866-1100
Country	:	US
Telephone Number	:	301-421-4000
Fax Number	:

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

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	07/08/2007

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