Provider Demographics
NPI:1558891291
Name:RICHARD C. EVANGELISTA D.D.S., INC.
Entity Type:Organization
Organization Name:RICHARD C. EVANGELISTA D.D.S., INC.
Other - Org Name:BEAUTIFUL SMILES OF LA JOLLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANGELISTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:925-789-0575
Mailing Address - Street 1:8861 VILLA LA JOLLA DR STE 501
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1925
Mailing Address - Country:US
Mailing Address - Phone:858-926-2332
Mailing Address - Fax:
Practice Address - Street 1:8861 VILLA LA JOLLA DR STE 501
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1925
Practice Address - Country:US
Practice Address - Phone:858-926-2332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RICHARD C. EVANGELISTA D.D.S. INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47258261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental