Healthcare Provider Details

I. General information

NPI: 1790171429
Provider Name (Legal Business Name): DR. ROBERT C. DAVIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 04/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 WEST 29TH STREET
PUEBLO CO
81008-1159
US

IV. Provider business mailing address

902 W 29TH ST
PUEBLO CO
81008-1159
US

V. Phone/Fax

Practice location:
  • Phone: 719-542-5300
  • Fax: 719-545-5525
Mailing address:
  • Phone: 719-542-5300
  • Fax: 719-545-5525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3556
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT C. DAVIS
Title or Position: DENTIST
Credential: DMD
Phone: 719-542-5300