Provider Demographics
NPI:1790095065
Name:CITY OF EVANSTON HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:CITY OF EVANSTON HEALTH DEPARTMENT
Other - Org Name:EVANSTON CHILDRENS DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:EVONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:RN MSN DHA(C)
Authorized Official - Phone:847-844-2957
Mailing Address - Street 1:2100 RIDGE AVE
Mailing Address - Street 2:ROOM G-500
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-2716
Mailing Address - Country:US
Mailing Address - Phone:847-866-2957
Mailing Address - Fax:847-448-8125
Practice Address - Street 1:2100 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2716
Practice Address - Country:US
Practice Address - Phone:847-866-2057
Practice Address - Fax:847-448-8125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL074390907251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare