MEDICARE: ELBERT R DAVIS DMD

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	DN16694	FL

General Provider Information

NPI Number	:	1487746673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELBERT R DAVIS DMD

Provider Business Mailing Address
First Line	:	201 EGLIN PKWY SE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5810
Country	:	US
Telephone Number	:	850-863-9050
Fax Number	:	850-863-5077

Provider Business Practice Location Address
First Line	:	201 EGLIN PKWY SE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5810
Country	:	US
Telephone Number	:	850-863-9050
Fax Number	:	850-863-5077

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

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	10/06/2011

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