Provider Demographics
NPI:1235274812
Name:EVELAND, KEITH WARE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:WARE
Last Name:EVELAND
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BOW ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-3838
Mailing Address - Country:US
Mailing Address - Phone:603-433-5677
Mailing Address - Fax:603-433-6279
Practice Address - Street 1:111 BOW ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-3838
Practice Address - Country:US
Practice Address - Phone:603-433-5677
Practice Address - Fax:603-433-6279
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12191223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH89191631Medicaid