Provider Demographics
NPI:1235435298
Name:G S EVANS DDS PA
Entity Type:Organization
Organization Name:G S EVANS DDS PA
Other - Org Name:STRAIGHT TEETH ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-337-5200
Mailing Address - Street 1:3434 W ILLINOIS AVE
Mailing Address - Street 2:SUITE204
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75211-8796
Mailing Address - Country:US
Mailing Address - Phone:214-337-5200
Mailing Address - Fax:214-337-5204
Practice Address - Street 1:3434 W ILLINOIS AVE
Practice Address - Street 2:SUITE204
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-8796
Practice Address - Country:US
Practice Address - Phone:214-337-5200
Practice Address - Fax:214-337-5204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX150301223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166592903Medicaid