Healthcare Provider Details

I. General information

NPI: 1306839329
Provider Name (Legal Business Name): NELSON CHARLES DAVIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PENTAGON TRISERVICE DENTAL CLINIC 5802 ARMY PENTAGON
WASHINGTON DC
20310-0001
US

IV. Provider business mailing address

710 S ROYAL ST
ALEXANDRIA VA
22314-4310
US

V. Phone/Fax

Practice location:
  • Phone: 703-692-8700
  • Fax: 703-692-6123
Mailing address:
  • Phone: 703-549-4382
  • Fax: 703-692-6123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN 4901
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: