MEDICARE: DR. JEREMY BLAZE DAVIDSON D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	0401412449	VA

General Provider Information

NPI Number	:	1811981954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEREMY BLAZE DAVIDSON D.D.S.

Provider Business Mailing Address
First Line	:	857 BISHOPSGATE LN
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-6181
Country	:	US
Telephone Number	:	210-837-0716
Fax Number	:

Provider Business Practice Location Address
First Line	:	401 N GREAT NECK RD STE 122
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-4063
Country	:	US
Telephone Number	:	757-962-2499
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	04/25/2019

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