Provider Demographics
NPI:1922457027
Name:EVANS, MICHELLE L (DENTAL ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:EVANS
Suffix:
Gender:F
Credentials:DENTAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4TH & INNER LOOP ROAD
Mailing Address - Street 2:BLDG 171
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310
Mailing Address - Country:US
Mailing Address - Phone:719-526-5537
Mailing Address - Fax:719-524-2843
Practice Address - Street 1:4TH & INNER LOOP ROAD
Practice Address - Street 2:BLDG 171
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310
Practice Address - Country:US
Practice Address - Phone:719-526-5537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant