Provider Demographics
NPI:1114229317
Name:EVANS, BRIAN DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DAVID
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 1:4796 PANORAMA DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-1239
Mailing Address - Country:US
Mailing Address - Phone:208-757-0787
Mailing Address - Fax:
Practice Address - Street 1:USS CARL VINSON CVN70
Practice Address - Street 2:UNIT 1000111 BOX 1770
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96629
Practice Address - Country:US
Practice Address - Phone:619-545-4814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA612301223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1863OtherGENERAL ANESTHESIA PERMIT
CA61230OtherDENTAL LICENSE
CA61230OtherDENTAL LICENSE