Provider Demographics
NPI:1730234725
Name:EVANS, DALE LEIGH (DDS)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:LEIGH
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 1:2104 NEWTON DR NE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2456
Mailing Address - Country:US
Mailing Address - Phone:770-787-0690
Mailing Address - Fax:770-787-0691
Practice Address - Street 1:2104 NEWTON DR NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2456
Practice Address - Country:US
Practice Address - Phone:770-787-0690
Practice Address - Fax:770-787-0691
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0077111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice