Provider Demographics
NPI:1063479830
Name:EVANS, CATHERINE BONITA (DDS)
Entity Type:Individual
Prefix:DR
First Name:CATHERINE
Middle Name:BONITA
Last Name:EVANS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:WADE
Mailing Address - State:NC
Mailing Address - Zip Code:28395-0449
Mailing Address - Country:US
Mailing Address - Phone:910-483-6694
Mailing Address - Fax:910-483-2215
Practice Address - Street 1:6540 CLINTON RD
Practice Address - Street 2:
Practice Address - City:STEDMAN
Practice Address - State:NC
Practice Address - Zip Code:28391-8846
Practice Address - Country:US
Practice Address - Phone:910-483-3150
Practice Address - Fax:910-483-2845
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC50111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8992514Medicaid
NC8992514Medicaid