Provider Demographics
NPI:1932467297
Name:BRUCE D. EVANS
Entity Type:Organization
Organization Name:BRUCE D. EVANS
Other - Org Name:HICKORY HILLS DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE CORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-766-8800
Mailing Address - Street 1:1947 FLORENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-2729
Mailing Address - Country:US
Mailing Address - Phone:256-766-8800
Mailing Address - Fax:256-766-8936
Practice Address - Street 1:1947 FLORENCE BLVD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-2729
Practice Address - Country:US
Practice Address - Phone:256-766-8800
Practice Address - Fax:256-766-8936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL34151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0843054OtherUNITED CONCORDIA
AL515-38965OtherBLUE CROSS BLUE SHIELD
AL009947460Medicaid