Provider Demographics
NPI:1235511882
Name:EVANS, GLENN (DMD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:EVANS
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 1:1151 E MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24141-1761
Mailing Address - Country:US
Mailing Address - Phone:540-639-1674
Mailing Address - Fax:640-639-9205
Practice Address - Street 1:1151 E MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-1761
Practice Address - Country:US
Practice Address - Phone:540-639-1674
Practice Address - Fax:640-639-9205
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401414899122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist