Healthcare Provider Details

I. General information

NPI: 1538474036
Provider Name (Legal Business Name): DAVIDSON FAMILY DENTAL/RAWLINS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2010
Last Update Date: 08/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 W SPRUCE ST
RAWLINS WY
82301-5211
US

IV. Provider business mailing address

1101 W. SPRUCE ST.
RAWLINS WY
82301
US

V. Phone/Fax

Practice location:
  • Phone: 307-324-3839
  • Fax:
Mailing address:
  • Phone: 307-324-3839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER WAYNE DAVIDSON
Title or Position: DENTIST
Credential: D.D.S.
Phone: 307-324-3839