MEDICARE: DR. MICHAEL J DAVIS 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	1223P0300X	Periodontics	13175	TX

General Provider Information

NPI Number	:	1821291014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL J DAVIS DDS

Provider Business Mailing Address
First Line	:	1818 8TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-1391
Country	:	US
Telephone Number	:	817-920-0882
Fax Number	:	817-920-0709

Provider Business Practice Location Address
First Line	:	1818 8TH AVENUE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110
Country	:	US
Telephone Number	:	817-920-0882
Fax Number	:	817-920-0709

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

Provider Enumeration Date	:	06/06/2007
Last Update Date	:	07/07/2010

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