Provider Demographics
NPI:1124018841
Name:EVANS, CARLOTTA ANN (DDS)
Entity type:Individual
Prefix:DR
First Name:CARLOTTA
Middle Name:ANN
Last Name:EVANS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:CARLA
Other - Middle Name:ANN
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:801 S PAULINA ST
Mailing Address - Street 2:MC 841
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7210
Mailing Address - Country:US
Mailing Address - Phone:312-996-7138
Mailing Address - Fax:312-996-0873
Practice Address - Street 1:801 S PAULINA ST
Practice Address - Street 2:MC 841
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7210
Practice Address - Country:US
Practice Address - Phone:312-996-7138
Practice Address - Fax:312-996-0873
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021-0017861223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA2741KD1Medicaid