Provider Demographics
NPI:1730568296
Name:EVANS, BENNIE CLEAVELAND (DDS)
Entity type:Individual
Prefix:
First Name:BENNIE
Middle Name:CLEAVELAND
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 1:210 ADDAVALE ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4217
Mailing Address - Country:US
Mailing Address - Phone:770-229-1490
Mailing Address - Fax:770-229-4929
Practice Address - Street 1:210 ADDAVALE ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4217
Practice Address - Country:US
Practice Address - Phone:770-229-1490
Practice Address - Fax:770-229-4929
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA84951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice