Provider Demographics
NPI:1073785010
Name:EVANS, BROCK D (DMD)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:D
Last Name:EVANS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 E LAMAR ALEXANDER PKWY
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-5131
Mailing Address - Country:US
Mailing Address - Phone:865-983-8630
Mailing Address - Fax:865-981-4914
Practice Address - Street 1:1505 E LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5131
Practice Address - Country:US
Practice Address - Phone:865-983-8630
Practice Address - Fax:865-981-4914
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS88071223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN8807OtherLICENSE
TN5442224Medicaid
TN5442224Medicaid