Provider Demographics
NPI:1295811339
Name:EVANS, FOREST LUKE (DDS)
Entity type:Individual
Prefix:DR
First Name:FOREST
Middle Name:LUKE
Last Name:EVANS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 531
Mailing Address - Street 2:
Mailing Address - City:BISHOPVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29010-0531
Mailing Address - Country:US
Mailing Address - Phone:803-484-6041
Mailing Address - Fax:803-484-6514
Practice Address - Street 1:101 HARRIS STREET,
Practice Address - Street 2:
Practice Address - City:BISHOPVILLE
Practice Address - State:SC
Practice Address - Zip Code:29010-0531
Practice Address - Country:US
Practice Address - Phone:803-484-6041
Practice Address - Fax:803-484-6514
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-08-01
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-01
Provider Licenses
StateLicense IDTaxonomies
SC16231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ1623-3Medicaid