Healthcare Provider Details

I. General information

NPI: 1811981954
Provider Name (Legal Business Name): JEREMY BLAZE DAVIDSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 04/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N GREAT NECK RD STE 122
VIRGINIA BEACH VA
23454-4063
US

IV. Provider business mailing address

857 BISHOPSGATE LN
VIRGINIA BEACH VA
23452-6181
US

V. Phone/Fax

Practice location:
  • Phone: 757-962-2499
  • Fax:
Mailing address:
  • Phone: 210-837-0716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0401412449
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: