Provider Demographics
NPI:1366732844
Name:EVANGELISTA, JONI
Entity type:Individual
Prefix:
First Name:JONI
Middle Name:
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1354 N WOLCOTT AVE
Mailing Address - Street 2:UNIT A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2750 W NORTH AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5247
Practice Address - Country:US
Practice Address - Phone:312-432-4550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.012553124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist