Provider Demographics
NPI:1497048664
Name:RICHARD B. EVANS, D.D.S., INC.
Entity Type:Organization
Organization Name:RICHARD B. EVANS, D.D.S., INC.
Other - Org Name:SUMMIT DENTAL OF LA MESA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-468-1828
Mailing Address - Street 1:8530 LA MESA BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-0966
Mailing Address - Country:US
Mailing Address - Phone:619-494-2492
Mailing Address - Fax:619-460-0700
Practice Address - Street 1:8530 LA MESA BLVD STE 204
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-0966
Practice Address - Country:US
Practice Address - Phone:619-460-0700
Practice Address - Fax:619-460-0707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-22
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X, 1223X0400X, 1223X2210X, 124Q00000X
CA31914261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223X2210XDental ProvidersDentistOrofacial PainGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty