Healthcare Provider Details

I. General information

NPI: 1770535544
Provider Name (Legal Business Name): DAVID K SEVERSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 TRUMP RD NW
CARROLLTON OH
44615-9472
US

IV. Provider business mailing address

1040 TRUMP RD NW P.O. BOX297
CARROLLTON OH
44615-9472
US

V. Phone/Fax

Practice location:
  • Phone: 218-831-3674
  • Fax:
Mailing address:
  • Phone: 218-831-3674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5772-015
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number30.023400
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.023400
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: