Healthcare Provider Details

I. General information

NPI: 1548403314
Provider Name (Legal Business Name): JACK A DAVIDSON DDS MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16141 FISHHAWK BLVD STE B
LITHIA FL
33547-4380
US

IV. Provider business mailing address

16141 FISHHAWK BLVD STE B
LITHIA FL
33547-4380
US

V. Phone/Fax

Practice location:
  • Phone: 813-571-1516
  • Fax: 813-571-1626
Mailing address:
  • Phone: 813-571-1516
  • Fax: 813-571-1626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10794
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberME72794
License Number StateFL

VIII. Authorized Official

Name: DR. JACK DAVIDSON JR.
Title or Position: DOCTOR
Credential: D.D.S, MD
Phone: 813-571-1516