Provider Demographics
NPI:1538142492
Name:EVANS, GLENN JEFFREY (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:JEFFREY
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 1:703 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3646
Mailing Address - Country:US
Mailing Address - Phone:630-362-8674
Mailing Address - Fax:630-752-9588
Practice Address - Street 1:703 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3646
Practice Address - Country:US
Practice Address - Phone:630-362-8674
Practice Address - Fax:630-752-9588
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026423122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist