Provider Demographics
NPI:1437248655
Name:EVANS, JOHN R (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:EVANS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 NE PACIFIC ST
Mailing Address - Street 2:BOX 357131
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-7131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:B241 HSB
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-7134
Practice Address - Country:US
Practice Address - Phone:206-534-7722
Practice Address - Fax:206-685-7222
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000046131223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5030838Medicaid
WA0175769OtherL&I
WA5030838Medicaid