Healthcare Provider Details

I. General information

NPI: 1952462749
Provider Name (Legal Business Name): RICHARD D DAVIDSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 N NILES AVE
TUSCOLA IL
61953-1059
US

IV. Provider business mailing address

703 N NILES AVE
TUSCOLA IL
61953-1059
US

V. Phone/Fax

Practice location:
  • Phone: 217-253-5216
  • Fax: 217-253-4949
Mailing address:
  • Phone: 217-253-5216
  • Fax: 217-253-4949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: