Provider Demographics
NPI:1134244734
Name:EVAN L PERRY DDS PC
Entity type:Organization
Organization Name:EVAN L PERRY DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-225-7111
Mailing Address - Street 1:320 RIVER PARK DR
Mailing Address - Street 2:SUITE 225
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6060
Mailing Address - Country:US
Mailing Address - Phone:801-225-7111
Mailing Address - Fax:801-764-9777
Practice Address - Street 1:320 RIVER PARK DR
Practice Address - Street 2:SUITE 225
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6060
Practice Address - Country:US
Practice Address - Phone:801-225-7111
Practice Address - Fax:801-764-9777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1421031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528906301003Medicaid