Provider Demographics
NPI:1548459829
Name:EVANOFF, GREGORY A (DDS)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:EVANOFF
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 1:1000 31ST AVE SW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-6958
Mailing Address - Country:US
Mailing Address - Phone:701-852-3222
Mailing Address - Fax:701-852-2767
Practice Address - Street 1:1000 31ST AVE SW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-6958
Practice Address - Country:US
Practice Address - Phone:701-852-3222
Practice Address - Fax:701-852-2767
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND17121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice