Provider Demographics
NPI:1760928584
Name:EVANS, ERICA (LDA, CDA, CHW)
Entity Type:Individual
Prefix:MS
First Name:ERICA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:LDA, CDA, CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 ANNE ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5113
Mailing Address - Country:US
Mailing Address - Phone:218-444-9646
Mailing Address - Fax:218-444-9252
Practice Address - Street 1:1405 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5113
Practice Address - Country:US
Practice Address - Phone:218-444-9646
Practice Address - Fax:218-444-9252
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA139221223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health