Healthcare Provider Details

I. General information

NPI: 1922293133
Provider Name (Legal Business Name): MILTON LEE DAVENPORT III D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 N LINCOLN PARK W
CHICAGO IL
60614-5487
US

IV. Provider business mailing address

1960 N LINCOLN PARK W
CHICAGO IL
60614-5487
US

V. Phone/Fax

Practice location:
  • Phone: 773-327-3131
  • Fax: 773-327-3208
Mailing address:
  • Phone: 773-327-3131
  • Fax: 773-327-3208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number21002223
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: