Provider Demographics
NPI:1568444990
Name:EVANS, ERIC (DDS)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
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:PSC 804 BOX 146
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 804 BOX 6
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09409
Practice Address - Country:US
Practice Address - Phone:44163-785-3569
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010304A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice