Provider Demographics
NPI:1013399641
Name:MARK DAVIS, DDS PC
Entity Type:Organization
Organization Name:MARK DAVIS, DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-947-4066
Mailing Address - Street 1:733 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1507
Mailing Address - Country:US
Mailing Address - Phone:541-947-4066
Mailing Address - Fax:541-947-3675
Practice Address - Street 1:2301 MOUNTAIN VIEW BLVD STE D
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1137
Practice Address - Country:US
Practice Address - Phone:541-882-9039
Practice Address - Fax:866-437-2057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8238261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental