=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841343316
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEACHTREE PERIODONTICS & DENTAL IMPLANTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2007
-----------------------------------------------------
Last Update Date | 10/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 STEVENS ENTRY
-----------------------------------------------------
City | PEACHTREE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30269-1325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-487-7734
-----------------------------------------------------
Fax | 770-487-1783
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 306 STEVENS ENTRY
-----------------------------------------------------
City | PEACHTREE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30269-1325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-487-7734
-----------------------------------------------------
Fax | 770-487-1783
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. DAVID ROBERT DAVENPORT
-----------------------------------------------------
Credential | DMD, MS
-----------------------------------------------------
Telephone | 770-487-7734
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 009974
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------