Provider Demographics
NPI:1194238584
Name:EVANS, MICHAEL BRIAN (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRIAN
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 1:440 OVERHILL ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-4825
Mailing Address - Country:US
Mailing Address - Phone:304-550-6005
Mailing Address - Fax:
Practice Address - Street 1:451 SUNCREST TOWN CENTRE DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-1814
Practice Address - Country:US
Practice Address - Phone:304-293-5831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-08
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4282122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist