Healthcare Provider Details

I. General information

NPI: 1386204451
Provider Name (Legal Business Name): UNDINE MELISSA DAVIS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 CENTER DR
GAINESVILLE FL
32610-3006
US

IV. Provider business mailing address

2558 SW 77TH ST
GAINESVILLE FL
32608-0315
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-5700
  • Fax:
Mailing address:
  • Phone: 408-807-0780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDRPM2042
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDRPM2042
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: