Provider Demographics
NPI:1114379898
Name:BEVANS, NATASJA (DMD)
Entity Type:Individual
Prefix:DR
First Name:NATASJA
Middle Name:
Last Name:BEVANS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 AUGUSTA ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-3503
Mailing Address - Country:US
Mailing Address - Phone:864-214-4242
Mailing Address - Fax:
Practice Address - Street 1:109 AUGUSTA ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3503
Practice Address - Country:US
Practice Address - Phone:864-214-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 22044122300000X
SC87601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist