Provider Demographics
NPI:1902026479
Name:RANDOLPH T. EVANS, D.D.S. P.L.L.C.
Entity Type:Organization
Organization Name:RANDOLPH T. EVANS, D.D.S. P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:TERRY
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-263-3131
Mailing Address - Street 1:22 SIERRA DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25403-1133
Mailing Address - Country:US
Mailing Address - Phone:304-263-3131
Mailing Address - Fax:304-263-4493
Practice Address - Street 1:22 SIERRA DRIVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25403-1133
Practice Address - Country:US
Practice Address - Phone:304-263-3131
Practice Address - Fax:304-263-4493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV29871223G0001X
WV37081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty