Provider Demographics
NPI:1104815042
Name:EVANS, LARRY JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:JAMES
Last Name:EVANS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13830 PALATINE HL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-7004
Mailing Address - Country:US
Mailing Address - Phone:707-592-5805
Mailing Address - Fax:
Practice Address - Street 1:2133 PEPPERRELL ST BLDG 3352
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236
Practice Address - Country:US
Practice Address - Phone:210-292-8627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX170741223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics