Provider Demographics
NPI:1508084856
Name:EVANS, MARK T (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
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 1:1676 LAWRENCEVILLE PLANK RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23868-3304
Mailing Address - Country:US
Mailing Address - Phone:434-848-3411
Mailing Address - Fax:
Practice Address - Street 1:1676 LAWRENCEVILLE PLANK RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:VA
Practice Address - Zip Code:23868-3304
Practice Address - Country:US
Practice Address - Phone:434-848-3411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401006342122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist