MEDICARE: DR. KIRK MICHAEL DAVIDSON 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	122300000X	Dentist	4322	ID

General Provider Information

NPI Number	:	1477850873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIRK MICHAEL DAVIDSON DDS

Provider Business Mailing Address
First Line	:	509 W HANLEY AVE
Second Line	:	STE. 201
City	:	COEUR D ALENE
State	:	ID
Zip	:	83815-8994
Country	:	US
Telephone Number	:	208-667-5447
Fax Number	:

Provider Business Practice Location Address
First Line	:	509 W HANLEY AVE
Second Line	:	STE. 201
City	:	COEUR D ALENE
State	:	ID
Zip	:	83815-8994
Country	:	US
Telephone Number	:	208-667-5447
Fax Number	:

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

Provider Enumeration Date	:	02/21/2011
Last Update Date	:	02/21/2011

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