Healthcare Provider Details

I. General information

NPI: 1902936248
Provider Name (Legal Business Name): C. EDGAR DAVILA DDS MS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4712 N ARMENIA AVE SUITE 100
TAMPA FL
33603-2611
US

IV. Provider business mailing address

4712 N ARMENIA AVE SUITE 100
TAMPA FL
33603-2611
US

V. Phone/Fax

Practice location:
  • Phone: 813-872-9313
  • Fax: 813-354-9446
Mailing address:
  • Phone: 813-872-9313
  • Fax: 813-354-9446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number13352
License Number StateFL

VIII. Authorized Official

Name: DR. CHRISTIAN EDGAR DAVILA
Title or Position: OWNER
Credential: DDS
Phone: 813-872-9313