Basic Information
Provider Information
NPI: 1063854339
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MCEVOY
FirstName: LISA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 600 CAISSON HILL RD
Address2:  
City: FORT RILEY
State: KS
PostalCode: 664427037
CountryCode: US
TelephoneNumber: 7852397241
FaxNumber:  
Practice Location
Address1: 440 E TAMPA ST
Address2:  
City: SPRINGFIELD
State: MO
PostalCode: 65806
CountryCode: US
TelephoneNumber: 4178511589
FaxNumber: 4178653479
Other Information
ProviderEnumerationDate: 07/26/2013
LastUpdateDate: 06/20/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X00202031COY Dental ProvidersDentist 

No ID Information.


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