Provider Demographics
NPI:1699086470
Name:EVANS, BEAU BARKER (DDS)
Entity type:Individual
Prefix:DR
First Name:BEAU
Middle Name:BARKER
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 1:202 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-5002
Mailing Address - Country:US
Mailing Address - Phone:918-652-4404
Mailing Address - Fax:918-652-4445
Practice Address - Street 1:202 S 6TH ST
Practice Address - Street 2:
Practice Address - City:HENRYETTA
Practice Address - State:OK
Practice Address - Zip Code:74437-5002
Practice Address - Country:US
Practice Address - Phone:918-652-4404
Practice Address - Fax:918-652-4445
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-28
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK61881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200302490AMedicaid