Provider Demographics
NPI:1245415348
Name:EVANS ENDODONTICS, P.C.
Entity Type:Organization
Organization Name:EVANS ENDODONTICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:309-661-8900
Mailing Address - Street 1:208 N WILLIAMSBURG DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3571
Mailing Address - Country:US
Mailing Address - Phone:309-661-8900
Mailing Address - Fax:309-661-8118
Practice Address - Street 1:208 N WILLIAMSBURG DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3571
Practice Address - Country:US
Practice Address - Phone:309-661-8900
Practice Address - Fax:309-661-8118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL210021081223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty