Healthcare Provider Details

I. General information

NPI: 1174154488
Provider Name (Legal Business Name): MS. ANDREA MARIE DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2020
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 AREA NAVAL DENTAL CLINIC CAMP PENDLETON
APO AA
92055
US

IV. Provider business mailing address

2505 RAYMELL DR
SAN DIEGO CA
92123-3543
US

V. Phone/Fax

Practice location:
  • Phone: 760-763-2106
  • Fax:
Mailing address:
  • Phone: 619-522-4210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: