=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336149715
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGIA A DAVIS DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 DIVISION ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21217-3121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-383-9800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3440 CARRIAGE HILL CIR
-----------------------------------------------------
City | RANDALLSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21133-3047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-496-0962
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 12317
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------