Provider Demographics
NPI:1922839638
Name:EVAN CHALK DMD PLLC
Entity type:Organization
Organization Name:EVAN CHALK DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHALK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:434-845-1121
Mailing Address - Street 1:1922 THOMSON DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1019
Mailing Address - Country:US
Mailing Address - Phone:434-845-1121
Mailing Address - Fax:434-845-1096
Practice Address - Street 1:1922 THOMSON DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1019
Practice Address - Country:US
Practice Address - Phone:434-845-1121
Practice Address - Fax:434-845-1096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA181724168551Medicaid