Provider Demographics
NPI:1801827837
Name:KNEALE, EVAN C (DDS)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:C
Last Name:KNEALE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11187 SHERIDAN BLVD
Mailing Address - Street 2:UNIT 12
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80020-3231
Mailing Address - Country:US
Mailing Address - Phone:303-469-2333
Mailing Address - Fax:303-469-2011
Practice Address - Street 1:11187 SHERIDAN BLVD
Practice Address - Street 2:UNIT 12
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80020-3231
Practice Address - Country:US
Practice Address - Phone:303-469-2333
Practice Address - Fax:303-469-2011
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO80271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO57002754Medicaid