=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891839072
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARY DAVIS DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2007
-----------------------------------------------------
Last Update Date | 07/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27758 SANTA MARGARITA PKWY SUITE334
-----------------------------------------------------
City | MISSION VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92691-6709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-554-4844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27758 SANTA MARGARITA PKWY SUITE334
-----------------------------------------------------
City | MISSION VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92691-6709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | GARY STEPHEN DAVIS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 949-554-4844
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 52166
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------