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General NPI Number Information
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NPI Number | 1255870051
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Entity Type | Organization
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Legal Business Name | JACKSON PEDIATRIC DENTISTRY PC
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Dates
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Enumeration Date | 02/14/2017
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Last Update Date | 02/14/2017
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Provider Practice Location Address
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Address Line | 2500 SPRING ARBOR RD
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City | JACKSON
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State | MI
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Zip | 49203-3602
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Country | US
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Telephone | 517-787-1022
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Fax |
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Provider Business Mailing Address
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Address Line | 2500 SPRING ARBOR RD
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City | JACKSON
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State | MI
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Zip | 49203-3602
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Country | US
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Telephone | 517-787-1022
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. STEVEN L DAVENPORT
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Credential | DDS
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Telephone | 517-787-1022
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 2901017187
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License Number State | MI
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