Provider Demographics
NPI:1003969312
Name:EVANS, BRUCE D (DMD,PC)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:D
Last Name:EVANS
Suffix:
Gender:M
Credentials:DMD,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1947 FLORENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-2729
Mailing Address - Country:US
Mailing Address - Phone:256-766-8800
Mailing Address - Fax:
Practice Address - Street 1:1947 FLORENCE BLVD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-2729
Practice Address - Country:US
Practice Address - Phone:256-766-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL34151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL650503830OtherT.I.N
AL843054OtherUNITED CONCORD
AL009947460Medicaid
AL92029OtherBLUE CROSS BLUE SHIELD
AL79378OtherSTATE ID.#