Provider Demographics
NPI:1851476766
Name:JAIME V. EVANGELISTA JR, D.M.D, INC.
Entity Type:Organization
Organization Name:JAIME V. EVANGELISTA JR, D.M.D, INC.
Other - Org Name:GATEWAY PLAZA DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:VICTORES
Authorized Official - Last Name:EVANGELISTA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:510-887-6835
Mailing Address - Street 1:24901 SANTA CLARA ST
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-2147
Mailing Address - Country:US
Mailing Address - Phone:510-887-6835
Mailing Address - Fax:510-887-2872
Practice Address - Street 1:24901 SANTA CLARA ST
Practice Address - Street 2:SUITE B-2
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-2147
Practice Address - Country:US
Practice Address - Phone:510-887-6835
Practice Address - Fax:510-887-2872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA371031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty