Provider Demographics
NPI:1619542396
Name:EVANS, BENJAMIN ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:ROBERT
Last Name:EVANS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 WALKMANS CV
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-7609
Mailing Address - Country:US
Mailing Address - Phone:260-494-9091
Mailing Address - Fax:
Practice Address - Street 1:10213 DUPONT CIRCLE DR W
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1656
Practice Address - Country:US
Practice Address - Phone:260-484-8596
Practice Address - Fax:260-484-8706
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013604A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist