Provider Demographics
NPI:1093523656
Name:SAN DIEGO MAXILLOFACIAL SURGERY, EVANS-HAMMER DENTAL CORPORATION
Entity type:Organization
Organization Name:SAN DIEGO MAXILLOFACIAL SURGERY, EVANS-HAMMER DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-335-8892
Mailing Address - Street 1:PO BOX 27028
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92198-1028
Mailing Address - Country:US
Mailing Address - Phone:805-455-6057
Mailing Address - Fax:
Practice Address - Street 1:2185 CITRACADO PKWY
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92029-4159
Practice Address - Country:US
Practice Address - Phone:805-455-6057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-27
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty