Provider Demographics
NPI:1316599020
Name:BLACK, EVAN MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:MICHAEL
Last Name:BLACK
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 1:200 MERCY CIR
Mailing Address - Street 2:BUILDING H-200 4TH FLOOR
Mailing Address - City:FPO
Mailing Address - State:AA
Mailing Address - Zip Code:92055
Mailing Address - Country:US
Mailing Address - Phone:760-719-4747
Mailing Address - Fax:
Practice Address - Street 1:200 MERCY CIR
Practice Address - Street 2:BUILDING H-200 4TH FLOOR
Practice Address - City:FPO
Practice Address - State:AA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-719-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0423401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice