1548303373 NPI number — FOREST L. EVANS, D.D.S., P. A.

Table of content: (NPI 1548303373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548303373 NPI number — FOREST L. EVANS, D.D.S., P. A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOREST L. EVANS, D.D.S., P. A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548303373
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 531
Provider Second Line Business Mailing Address:
101 HARRIS ST.
Provider Business Mailing Address City Name:
BISHOPVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29010-0531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-484-6041
Provider Business Mailing Address Fax Number:
803-484-6514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 HARRIS ST.
Provider Second Line Business Practice Location Address:
BOX 531
Provider Business Practice Location Address City Name:
BISHOPVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29010-0531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-484-6041
Provider Business Practice Location Address Fax Number:
803-484-6514
Provider Enumeration Date:
02/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
DORA
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
P.A. SECRETARY
Authorized Official Telephone Number:
803-484-6041

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  1623 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZA 9699 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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