Provider Demographics
NPI:1093819591
Name:BENNIE C. EVANS,D.D.S.,P.C.
Entity Type:Organization
Organization Name:BENNIE C. EVANS,D.D.S.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENNIE
Authorized Official - Middle Name:CLEVELAND
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-229-1490
Mailing Address - Street 1:210 ADDAVALE ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4217
Mailing Address - Country:US
Mailing Address - Phone:770-229-1490
Mailing Address - Fax:770-229-4929
Practice Address - Street 1:210 ADDAVALE ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4217
Practice Address - Country:US
Practice Address - Phone:770-229-1490
Practice Address - Fax:770-229-4929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA84951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty