MEDICARE: JEREMY B. DAVIDSON DDS 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	0401412449	VA

General Provider Information

NPI Number	:	1841552528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEREMY B. DAVIDSON DDS PC

Provider Business Mailing Address
First Line	:	401 N GREAT NECK RD
Second Line	:	SUITE 122
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-4063
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	401 N GREAT NECK RD
Second Line	:	SUITE 122
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-4063
Country	:	US
Telephone Number	:	504-834-4392
Fax Number	:

Authorized Official
Title or Position	:	OWNER DOCTOR
Name	:	DR. JEREMY B DAVIDSON
Credential	:	DDS PC
Telephone Number	:	504-620-3400

Provider Enumeration Date	:	06/08/2012
Last Update Date	:	06/08/2012

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