Provider Demographics
NPI:1750839957
Name:EVANGELISTA, JR, JAIME V. (DMD)
Entity Type:Individual
Prefix:
First Name:JAIME V.
Middle Name:
Last Name:EVANGELISTA, JR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24901 SANTA CLARA ST # B2
Mailing Address - Street 2:HAYWARD
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-2147
Mailing Address - Country:US
Mailing Address - Phone:510-887-6835
Mailing Address - Fax:510-887-2872
Practice Address - Street 1:24901 SANTA CLARA ST # B2
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-2147
Practice Address - Country:US
Practice Address - Phone:510-887-6835
Practice Address - Fax:510-887-2872
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37103122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist