Provider Demographics
NPI:1649313453
Name:EVANS, CHARLES L (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
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 1:2140 W SAINT PAUL AVE STE A
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5905
Mailing Address - Country:US
Mailing Address - Phone:262-547-2827
Mailing Address - Fax:262-547-1269
Practice Address - Street 1:2140 W SAINT PAUL AVE STE A
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5905
Practice Address - Country:US
Practice Address - Phone:262-547-2827
Practice Address - Fax:262-547-1269
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0379G1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics