Healthcare Provider Details

I. General information

NPI: 1033589734
Provider Name (Legal Business Name): DAVISON FAMILY DENTISTRY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 10/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1058 N IRISH RD
DAVISON MI
48423-2209
US

IV. Provider business mailing address

1090 NORTHCHASE PKWY SE STE 150
MARIETTA GA
30067-6405
US

V. Phone/Fax

Practice location:
  • Phone: 810-653-4100
  • Fax:
Mailing address:
  • Phone: 770-916-5031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JOHN WILTZ
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 770-916-5031