Healthcare Provider Details

I. General information

NPI: 1730252982
Provider Name (Legal Business Name): TROY D DAVIDSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 PEACHTREE PKWY BLDG400, SUITE 4250
CUMMING GA
30041-7066
US

IV. Provider business mailing address

2552 BAGLEY RD
CUMMING GA
30041-7209
US

V. Phone/Fax

Practice location:
  • Phone: 770-622-1515
  • Fax:
Mailing address:
  • Phone: 801-602-5541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6545604-9923
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number23737
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE00010701
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD-4407-PD
License Number StateID
# 5
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number27304
License Number StateTX
# 6
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN014629
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: