Provider Demographics
NPI:1174018436
Name:EVANS, JAKE L
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:L
Last Name:EVANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 MIRROR LAKE RD
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-6160
Mailing Address - Country:US
Mailing Address - Phone:229-325-4381
Mailing Address - Fax:
Practice Address - Street 1:138 OAKLAND PKWY
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-7200
Practice Address - Country:US
Practice Address - Phone:229-432-2213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1015660122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist