Healthcare Provider Details

I. General information

NPI: 1750762076
Provider Name (Legal Business Name): TREVOR M DAVIS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E HWY 550
BERNALILLO NM
87004-5967
US

IV. Provider business mailing address

120 E HWY 550
BERNALILLO NM
87004-5967
US

V. Phone/Fax

Practice location:
  • Phone: 505-393-5555
  • Fax:
Mailing address:
  • Phone: 505-393-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4303
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: