Provider Demographics
NPI:1215337951
Name:SALLY A. EVANS DMD PC
Entity type:Organization
Organization Name:SALLY A. EVANS DMD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-340-4304
Mailing Address - Street 1:819 THOMPSON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-1774
Mailing Address - Country:US
Mailing Address - Phone:770-535-8900
Mailing Address - Fax:770-535-8108
Practice Address - Street 1:819 THOMPSON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-1774
Practice Address - Country:US
Practice Address - Phone:770-535-8900
Practice Address - Fax:770-535-8108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-31
Last Update Date:2014-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO13552261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental