Healthcare Provider Details

I. General information

NPI: 1184248544
Provider Name (Legal Business Name): MASON ROSS DAVIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1623 S PEORIA AVE
TULSA OK
74120-6203
US

IV. Provider business mailing address

1623 S PEORIA AVE
TULSA OK
74120-6203
US

V. Phone/Fax

Practice location:
  • Phone: 918-585-2254
  • Fax:
Mailing address:
  • Phone: 918-585-2254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7299
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: