Provider Demographics
NPI:1609058668
Name:EVANS, GRACE S (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:S
Last Name:EVANS
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 N DIXIE HWY
Mailing Address - Street 2:PO BOX 24
Mailing Address - City:WAPAKONETA
Mailing Address - State:OH
Mailing Address - Zip Code:45895-7749
Mailing Address - Country:US
Mailing Address - Phone:419-738-6944
Mailing Address - Fax:419-738-1444
Practice Address - Street 1:715 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:WAPAKONETA
Practice Address - State:OH
Practice Address - Zip Code:45895-7749
Practice Address - Country:US
Practice Address - Phone:419-738-6944
Practice Address - Fax:419-738-1444
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH218951223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics