Provider Demographics
NPI:1548900699
Name:EVANGELIDIS, JESSICA BETH (RDH, OMT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:BETH
Last Name:EVANGELIDIS
Suffix:
Gender:F
Credentials:RDH, OMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 VANESTA DR
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-0387
Mailing Address - Country:US
Mailing Address - Phone:816-225-8734
Mailing Address - Fax:
Practice Address - Street 1:3601 VANESTA DR
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66503-0387
Practice Address - Country:US
Practice Address - Phone:816-225-8734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10714124Q00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No124Q00000XDental ProvidersDental Hygienist