Provider Demographics
NPI:1407319569
Name:EVANS, KEIARA JERAI (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEIARA
Middle Name:JERAI
Last Name:EVANS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 PORTSMOUTH BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-2140
Mailing Address - Country:US
Mailing Address - Phone:757-517-2438
Mailing Address - Fax:
Practice Address - Street 1:3414 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2714
Practice Address - Country:US
Practice Address - Phone:347-377-4485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-07
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA04014176591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program