Provider Demographics
NPI:1861814295
Name:BEAU EVANS FAMILY DENTISTRY PLLC
Entity Type:Organization
Organization Name:BEAU EVANS FAMILY DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:BARKER
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-652-4404
Mailing Address - Street 1:202 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-5002
Mailing Address - Country:US
Mailing Address - Phone:918-652-4404
Mailing Address - Fax:918-652-4445
Practice Address - Street 1:202 S 6TH ST
Practice Address - Street 2:
Practice Address - City:HENRYETTA
Practice Address - State:OK
Practice Address - Zip Code:74437-5002
Practice Address - Country:US
Practice Address - Phone:918-652-4404
Practice Address - Fax:918-652-4445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK61881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty