Provider Demographics
NPI:1184627150
Name:EVANS, JOEL B
Entity type:Individual
Prefix:DR
First Name:JOEL
Middle Name:B
Last Name:EVANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 DALY DR
Mailing Address - Street 2:STE 310
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-3707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4501 DALY DR
Practice Address - Street 2:STE 310
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-3707
Practice Address - Country:US
Practice Address - Phone:703-378-1010
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010067691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice