Provider Demographics
NPI:1033282470
Name:DAVIS, DWIGHT RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:RICHARD
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 N VINE ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:PA
Mailing Address - Zip Code:17851-1314
Mailing Address - Country:US
Mailing Address - Phone:570-339-5170
Mailing Address - Fax:570-339-6606
Practice Address - Street 1:219 N VINE ST
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:PA
Practice Address - Zip Code:17851-1314
Practice Address - Country:US
Practice Address - Phone:570-339-5170
Practice Address - Fax:570-339-6606
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS019462L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist