Provider Demographics
NPI:1114384914
Name:DALE L EVANS LLC
Entity Type:Organization
Organization Name:DALE L EVANS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:L
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-787-0690
Mailing Address - Street 1:2104 NEWTON DR NE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2456
Mailing Address - Country:US
Mailing Address - Phone:770-787-0690
Mailing Address - Fax:770-787-0691
Practice Address - Street 1:2104 NEWTON DR NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2456
Practice Address - Country:US
Practice Address - Phone:770-787-0690
Practice Address - Fax:770-787-0691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental