Provider Demographics
NPI:1568682276
Name:EVANS, RANDOLPH TERRY (DDS PLLC)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:TERRY
Last Name:EVANS
Suffix:
Gender:M
Credentials:DDS PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 SIERRA DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25403-1133
Mailing Address - Country:US
Mailing Address - Phone:304-263-3131
Mailing Address - Fax:304-263-4493
Practice Address - Street 1:22 SIERRA DRIVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25403-1133
Practice Address - Country:US
Practice Address - Phone:304-263-3131
Practice Address - Fax:304-263-4493
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV29871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice