Provider Demographics
NPI:1841591658
Name:EVANGELISTA DENTAL CARE, PLLC
Entity Type:Organization
Organization Name:EVANGELISTA DENTAL CARE, PLLC
Other - Org Name:BEYOND SMILES DENTAL,CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWINA
Authorized Official - Middle Name:JIMENEZ
Authorized Official - Last Name:EVANGELISTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-232-4600
Mailing Address - Street 1:6600 NORTH FWY STE 109
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-7556
Mailing Address - Country:US
Mailing Address - Phone:817-232-4600
Mailing Address - Fax:817-232-4610
Practice Address - Street 1:6600 NORTH FWY STE 109
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-7556
Practice Address - Country:US
Practice Address - Phone:817-232-4600
Practice Address - Fax:817-232-4610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1992914758Medicaid