Healthcare Provider Details

I. General information

NPI: 1770343311
Provider Name (Legal Business Name): ERIC DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6211 W WILLIAM CANNON DR
AUSTIN TX
78749-1923
US

IV. Provider business mailing address

1700 WILLOW CREEK DR UNIT 382
AUSTIN TX
78741-4392
US

V. Phone/Fax

Practice location:
  • Phone: 737-263-5202
  • Fax:
Mailing address:
  • Phone: 908-247-2573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number41359
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: