Healthcare Provider Details

I. General information

NPI: 1538898903
Provider Name (Legal Business Name): RYAN A DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 CENTRAL AVE
FILLMORE CA
93015-1920
US

IV. Provider business mailing address

1040 FLYNN RD
CAMARILLO CA
93012-5092
US

V. Phone/Fax

Practice location:
  • Phone: 805-524-4926
  • Fax: 805-524-4137
Mailing address:
  • Phone: 805-673-3930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number110723
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: