Provider Demographics
NPI:1215396809
Name:DR JAIME V. EVANGELISTA JR., DMD
Entity Type:Organization
Organization Name:DR JAIME V. EVANGELISTA JR., DMD
Other - Org Name:GATEWAY PLAZA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:V
Authorized Official - Last Name:EVANGELISTA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:510-887-6835
Mailing Address - Street 1:24901 SANTA CLARA ST # B2
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-2147
Mailing Address - Country:US
Mailing Address - Phone:510-887-6835
Mailing Address - Fax:510-887-2872
Practice Address - Street 1:24901 SANTA CLARA ST # B2
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-2147
Practice Address - Country:US
Practice Address - Phone:510-887-6835
Practice Address - Fax:510-887-2872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37103122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty