Provider Demographics
NPI:1780931279
Name:EVANS, AUSTIN (DMD)
Entity type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 SAN PEDRO DR SE BLDG 48
Mailing Address - Street 2:377TH DENTAL SQUADRON
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-5153
Mailing Address - Country:US
Mailing Address - Phone:505-846-3065
Mailing Address - Fax:
Practice Address - Street 1:340 BOATNER ROAD
Practice Address - Street 2:
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542
Practice Address - Country:US
Practice Address - Phone:850-883-8050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY91791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice