Provider Demographics
NPI:1932299187
Name:EVANS, GARY L (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:EVANS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 E ELIZABETH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3951
Mailing Address - Country:US
Mailing Address - Phone:970-221-1926
Mailing Address - Fax:970-221-1888
Practice Address - Street 1:1040 E. ELIZABETH STREET
Practice Address - Street 2:SUITE D
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524
Practice Address - Country:US
Practice Address - Phone:970-221-1926
Practice Address - Fax:970-221-1888
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO054491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice