Healthcare Provider Details

I. General information

NPI: 1356639876
Provider Name (Legal Business Name): DAVIS DO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 W POINT LOMA BLVD
SAN DIEGO CA
92110-5603
US

IV. Provider business mailing address

11235 LEE WAY APT 15102
SAN DIEGO CA
92126-3070
US

V. Phone/Fax

Practice location:
  • Phone: 619-701-6622
  • Fax:
Mailing address:
  • Phone: 626-380-7626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number101970
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: