Provider Demographics
NPI:1689824971
Name:EVANS, CONNIE H
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:H
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78221-3117
Mailing Address - Country:US
Mailing Address - Phone:210-334-3700
Mailing Address - Fax:210-922-0162
Practice Address - Street 1:3750 COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78221-3117
Practice Address - Country:US
Practice Address - Phone:210-334-3700
Practice Address - Fax:210-923-4167
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14587124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX14587OtherTX STATE BOARD OF DENTAL EXAMINERS