Provider Demographics
NPI:1093799009
Name:EVANS, CLINTON WILKINSON (MD, DMD)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:WILKINSON
Last Name:EVANS
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 HAMPTON WAY
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-6319
Mailing Address - Country:US
Mailing Address - Phone:334-792-1158
Mailing Address - Fax:334-702-6983
Practice Address - Street 1:216 HEALTHWEST DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-1942
Practice Address - Country:US
Practice Address - Phone:334-792-1158
Practice Address - Fax:334-702-6983
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL227851223S0112X
AL45631223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000095652Medicaid
AL51097740OtherBCBSAL ENTERPRISE OFFICE
AL51095652OtherBCBSAL DOTHAN OFFICE
AL766464OtherUNITED CONCORDIA
AL000095652Medicare ID - Type Unspecified
AL51097740OtherBCBSAL ENTERPRISE OFFICE