Provider Demographics
NPI:1013294792
Name:DR. G. RANDALL EVANS, D.D.S., F.A.G.D.
Entity Type:Organization
Organization Name:DR. G. RANDALL EVANS, D.D.S., F.A.G.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:903-454-0918
Mailing Address - Street 1:4319 RIDGECREST RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75402-6004
Mailing Address - Country:US
Mailing Address - Phone:903-454-0918
Mailing Address - Fax:903-454-7540
Practice Address - Street 1:4319 RIDGECREST RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75402-6004
Practice Address - Country:US
Practice Address - Phone:903-454-0918
Practice Address - Fax:903-454-7540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118001223G0001X
TX215481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty