Provider Demographics
NPI:1598800039
Name:FAIRMONT DENTAL INC
Entity Type:Organization
Organization Name:FAIRMONT DENTAL INC
Other - Org Name:SAMUEL G EVANS JR DDS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-628-7166
Mailing Address - Street 1:304 IONA ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28340-1618
Mailing Address - Country:US
Mailing Address - Phone:910-628-7166
Mailing Address - Fax:910-628-7167
Practice Address - Street 1:304 IONA ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:NC
Practice Address - Zip Code:28340-1618
Practice Address - Country:US
Practice Address - Phone:910-628-7166
Practice Address - Fax:910-628-7167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC52861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
92534OtherBLUE CROSS BLUE SHIELD
NC8992534Medicaid
92534OtherBLUE CROSS BLUE SHIELD