Provider Demographics
NPI:1710127022
Name:EVANS, SAMUEL GENE JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:GENE
Last Name:EVANS
Suffix:JR
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 1:304 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:910-682-7167
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:910-682-7167
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-26
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5286122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist