Provider Demographics
NPI:1013174895
Name:SARA L EVANS DMD PC
Entity Type:Organization
Organization Name:SARA L EVANS DMD PC
Other - Org Name:NORTHWEST FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-556-0002
Mailing Address - Street 1:PO BOX 1029
Mailing Address - Street 2:
Mailing Address - City:RAINIER
Mailing Address - State:OR
Mailing Address - Zip Code:97048-1029
Mailing Address - Country:US
Mailing Address - Phone:503-556-0002
Mailing Address - Fax:503-556-4147
Practice Address - Street 1:608 B STREET W
Practice Address - Street 2:
Practice Address - City:RAINIER
Practice Address - State:OR
Practice Address - Zip Code:97048
Practice Address - Country:US
Practice Address - Phone:503-556-0002
Practice Address - Fax:503-556-4147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD66041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty