Provider Demographics
NPI:1609125533
Name:EVANS, KATHLEEN ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ANN
Last Name:EVANS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6411 STATE HIGHWAY 28
Mailing Address - Street 2:
Mailing Address - City:FLY CREEK
Mailing Address - State:NY
Mailing Address - Zip Code:13337-3007
Mailing Address - Country:US
Mailing Address - Phone:607-547-1291
Mailing Address - Fax:607-547-5828
Practice Address - Street 1:6411 STATE HIGHWAY 28
Practice Address - Street 2:
Practice Address - City:FLY CREEK
Practice Address - State:NY
Practice Address - Zip Code:13337-3007
Practice Address - Country:US
Practice Address - Phone:607-547-1291
Practice Address - Fax:607-547-5828
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0456601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice