Provider Demographics
NPI:1487714937
Name:EVANS, ALAN BLAKE (DDS)
Entity type:Individual
Prefix:MR
First Name:ALAN
Middle Name:BLAKE
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 1:1612 PLAZA PLACE
Mailing Address - Street 2:
Mailing Address - City:MUSCATINE
Mailing Address - State:IA
Mailing Address - Zip Code:52761-5364
Mailing Address - Country:US
Mailing Address - Phone:563-264-1180
Mailing Address - Fax:563-288-2776
Practice Address - Street 1:1612 PLAZA PLACE
Practice Address - Street 2:
Practice Address - City:MUSCATINE
Practice Address - State:IA
Practice Address - Zip Code:52761-5364
Practice Address - Country:US
Practice Address - Phone:563-264-1180
Practice Address - Fax:563-288-2776
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA079851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2191080Medicaid