Organization
FAIRMONT DENTAL INC
Active
Other names
Samuel G Evans Jr DDS
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SAMUEL G EVANS JR. DDS (PRESIDENT CEO)
(910) 628-7166
Entity
Organization
Contact information
Practice address
304 IONA ST, FAIRMONT, NC 28340-1618
(910) 628-7166
(910) 628-7167
Mailing address
304 IONA ST, FAIRMONT, NC 28340-1618
(910) 628-7166
(910) 628-7167
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
5286
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8992534
—
NC
01
—
92534
BLUE CROSS BLUE SHIELD
—
Enumeration date
02/21/2007
Last updated
01/17/2012
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