Provider Demographics
NPI:1902806094
Name:EVENSON, JOHN WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:EVENSON
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:PO BOX 821
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MN
Mailing Address - Zip Code:55943-0821
Mailing Address - Country:US
Mailing Address - Phone:507-896-3976
Mailing Address - Fax:
Practice Address - Street 1:109 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MN
Practice Address - Zip Code:55943-8449
Practice Address - Country:US
Practice Address - Phone:507-896-2202
Practice Address - Fax:507-896-3363
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice