Provider Demographics
NPI:1922017169
Name:RICHARD A. EVANSECK, DDS,PC
Entity Type:Organization
Organization Name:RICHARD A. EVANSECK, DDS,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:EVANSECK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-664-2115
Mailing Address - Street 1:1007 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2503
Mailing Address - Country:US
Mailing Address - Phone:765-664-2115
Mailing Address - Fax:765-664-2124
Practice Address - Street 1:1007 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2503
Practice Address - Country:US
Practice Address - Phone:765-664-2115
Practice Address - Fax:765-664-2124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120096601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty