MEDICARE: RUSSELL M DAVIS JR. DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5239	LA

General Provider Information

NPI Number	:	1083628143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL M DAVIS JR. DDS

Provider Business Mailing Address
First Line	:	409 N MAIN ST
Second Line	:
City	:	SAINT MARTINVILLE
State	:	LA
Zip	:	70582-4118
Country	:	US
Telephone Number	:	337-391-3111
Fax Number	:	337-394-3167

Provider Business Practice Location Address
First Line	:	409 N MAIN ST
Second Line	:
City	:	SAINT MARTINVILLE
State	:	LA
Zip	:	70582-4118
Country	:	US
Telephone Number	:	337-391-3111
Fax Number	:	337-394-3167

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	07/21/2022

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