MEDICARE: DR. GRANT A DAVIDSON

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	122300000X	Dentist	4060	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4060	OTHER	AR	LICENSE NUMBER

General Provider Information

NPI Number	:	1164805511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRANT A DAVIDSON

Provider Business Mailing Address
First Line	:	1874 N HUNTERS RDG
Second Line	:	SUITE 1
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72701-2774
Country	:	US
Telephone Number	:	479-442-5092
Fax Number	:	479-587-0932

Provider Business Practice Location Address
First Line	:	1874 N HUNTERS RDG
Second Line	:	SUITE 1
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72701-2774
Country	:	US
Telephone Number	:	479-442-5092
Fax Number	:	479-587-0932

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

Provider Enumeration Date	:	07/02/2015
Last Update Date	:	07/02/2015

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Directions to “ DR. GRANT A DAVIDSON ” Practice Location

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