Provider Demographics
NPI:1740387422
Name:EVANS, WILLIAM WALKER (DMD, MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:WALKER
Last Name:EVANS
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 EUREKA WAY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0230
Mailing Address - Country:US
Mailing Address - Phone:530-241-6374
Mailing Address - Fax:530-241-5140
Practice Address - Street 1:2710 EUREKA WAY
Practice Address - Street 2:SUITE 3
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0230
Practice Address - Country:US
Practice Address - Phone:530-241-6374
Practice Address - Fax:530-241-5140
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 554731223S0112X
MA177161223S0112X
CAOMS 201223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB89020-01Medicaid
CA00A554730Medicare ID - Type Unspecified
CAB89020-01Medicaid