Provider Demographics
NPI:1063854339
Name:MCEVOY, LISA (DDS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MCEVOY
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 1:600 CAISSON HILL RD
Mailing Address - Street 2:
Mailing Address - City:FORT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-7037
Mailing Address - Country:US
Mailing Address - Phone:785-239-7241
Mailing Address - Fax:
Practice Address - Street 1:440 E TAMPA ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806
Practice Address - Country:US
Practice Address - Phone:417-851-1589
Practice Address - Fax:417-865-3479
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-26
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00202031122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist