Provider Demographics
NPI:1215009923
Name:EVANS, KEITH ALLEN (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ALLEN
Last Name:EVANS
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 N REGENCY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3515
Mailing Address - Country:US
Mailing Address - Phone:309-661-8900
Mailing Address - Fax:309-661-8118
Practice Address - Street 1:113 N REGENCY DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3515
Practice Address - Country:US
Practice Address - Phone:309-661-8900
Practice Address - Fax:309-661-8118
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-025805122300000X
NC7391122300000X
IL021-0021081223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist