Provider Demographics
NPI:1578126793
Name:JOSEPH, EVAN
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3172 ROSWELL RD NW APT 1315
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-2335
Mailing Address - Country:US
Mailing Address - Phone:423-847-5239
Mailing Address - Fax:
Practice Address - Street 1:300 HOSPITAL DR STE 4
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-1921
Practice Address - Country:US
Practice Address - Phone:662-327-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1232121223S0112X
MS4397-231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty