Provider Demographics
NPI:1750867800
Name:EVANGELISTA DE LEON, REIMY (DDS)
Entity Type:Individual
Prefix:
First Name:REIMY
Middle Name:
Last Name:EVANGELISTA DE LEON
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 1:40A TIMBER LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7204
Mailing Address - Country:US
Mailing Address - Phone:802-862-7185
Mailing Address - Fax:
Practice Address - Street 1:40A TIMBER LN
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7204
Practice Address - Country:US
Practice Address - Phone:802-862-7185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2023-11-13
Deactivation Date:2019-02-13
Deactivation Code:
Reactivation Date:2019-03-25
Provider Licenses
StateLicense IDTaxonomies
VT016.01340381223X2210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X2210XDental ProvidersDentistOrofacial Pain