Provider Demographics
NPI:1558524561
Name:CHALK, EVAN C (DMD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:C
Last Name:CHALK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1922 THOMSON DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1019
Mailing Address - Country:US
Mailing Address - Phone:434-845-1121
Mailing Address - Fax:434-845-1096
Practice Address - Street 1:1922 THOMSON DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1019
Practice Address - Country:US
Practice Address - Phone:434-845-1121
Practice Address - Fax:434-845-1096
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04380003351223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1487659991OtherPRACTICE NPI