Healthcare Provider Details

I. General information

NPI: 1053591313
Provider Name (Legal Business Name): DENNIS W DAVIS IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS BUFFALO (SSN 715) COMNAVMARIANAS
SANTA RITA GU
96915
US

IV. Provider business mailing address

USS BUFFALO (SSN 715)
FPO AP
96661
US

V. Phone/Fax

Practice location:
  • Phone: 671-564-3022
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: