MEDICARE: JACKSON PEDIATRIC DENTISTRY PC

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	1223P0221X	Pediatric Dentistry	2901017187	MI

General Provider Information

NPI Number	:	1255870051
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON PEDIATRIC DENTISTRY PC

Provider Business Mailing Address
First Line	:	2500 SPRING ARBOR RD
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49203-3602
Country	:	US
Telephone Number	:	517-787-1022
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 SPRING ARBOR RD
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49203-3602
Country	:	US
Telephone Number	:	517-787-1022
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. STEVEN L DAVENPORT
Credential	:	DDS
Telephone Number	:	517-787-1022

Provider Enumeration Date	:	02/14/2017
Last Update Date	:	02/14/2017

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