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General NPI Number Information
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NPI Number | 1881950954
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Entity Type | Organization
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Legal Business Name | DAVIS PERIODONTICS
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Dates
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Enumeration Date | 04/03/2012
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Last Update Date | 04/03/2012
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Provider Practice Location Address
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Address Line | 5850 E 2ND ST STE 100
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City | CASPER
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State | WY
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Zip | 82609-4342
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Country | US
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Telephone | 307-472-0207
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Fax | 307-472-0259
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Provider Business Mailing Address
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Address Line | 5850 E 2ND ST STE 100
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City | CASPER
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State | WY
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Zip | 82609-4342
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Country | US
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Telephone | 307-472-0207
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Fax | 307-472-0259
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Authorized Official
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Title or Position | DENTIST
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Name | DR. MICHAEL A DAVIS
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Credential | DDS
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Telephone | 307-472-0207
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 1274
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License Number State | WY
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