Healthcare Provider Details

I. General information

NPI: 1265840896
Provider Name (Legal Business Name): DR. LARRY DENNIS DAVIS SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 W GORDON AVE STE A
ALBANY GA
31701-4515
US

IV. Provider business mailing address

1613 GLENRIDGE DR
NASHVILLE TN
37221-5303
US

V. Phone/Fax

Practice location:
  • Phone: 229-352-6610
  • Fax:
Mailing address:
  • Phone: 615-364-4273
  • Fax: 615-292-9056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN122431
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number04552
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8673
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3979-18
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: