Healthcare Provider Details

I. General information

NPI: 1871034702
Provider Name (Legal Business Name): JOHN TAYLOR MATTHEW DAVIS D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JT DAVIS D.M.D.

II. Dates (important events)

Enumeration Date: 03/11/2017
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 S SHORE DR
DESTIN FL
32550-5821
US

IV. Provider business mailing address

30 S SHORE DR
DESTIN FL
32550-5821
US

V. Phone/Fax

Practice location:
  • Phone: 205-994-5417
  • Fax:
Mailing address:
  • Phone: 205-994-5417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number122300000X
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: