Healthcare Provider Details

I. General information

NPI: 1619197332
Provider Name (Legal Business Name): NATHAN T DAVIS DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 S POWER RD STE 128
MESA AZ
85209
US

IV. Provider business mailing address

2500 S POWER RD STE 128
MESA AZ
85209
US

V. Phone/Fax

Practice location:
  • Phone: 480-969-8500
  • Fax: 480-969-8503
Mailing address:
  • Phone: 480-969-8500
  • Fax: 480-969-8503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberAZ4914
License Number StateAZ

VIII. Authorized Official

Name: DR. NATHAN TRENT DAVIS
Title or Position: PRESIDENT
Credential: DDS
Phone: 480-969-8500