1922457027 NPI number — MICHELLE L EVANS DENTAL ASSISTANT

Table of content: MICHELLE L EVANS DENTAL ASSISTANT (NPI 1922457027)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922457027 NPI number — MICHELLE L EVANS DENTAL ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
MICHELLE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DENTAL ASSISTANT
Provider Gender Code:
F

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:
1922457027
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4TH & INNER LOOP ROAD
Provider Second Line Business Mailing Address:
BLDG 171
Provider Business Mailing Address City Name:
FORT IRWIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-526-5537
Provider Business Mailing Address Fax Number:
719-524-2843

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4TH & INNER LOOP ROAD
Provider Second Line Business Practice Location Address:
BLDG 171
Provider Business Practice Location Address City Name:
FORT IRWIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-526-5537
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 126800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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