Healthcare Provider Details

I. General information

NPI: 1033681523
Provider Name (Legal Business Name): CRYSTAL NICHOLE DAVIS RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2018
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7525 N CEDAR AVE STE 105
FRESNO CA
93720-2698
US

IV. Provider business mailing address

7525 N CEDAR AVE STE 105
FRESNO CA
93720-2698
US

V. Phone/Fax

Practice location:
  • Phone: 559-439-6600
  • Fax:
Mailing address:
  • Phone: 559-439-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberRDA87859
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: