Provider Demographics
NPI:1033681523
Name:DAVIS, CRYSTAL NICHOLE (RDA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:NICHOLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7525 N CEDAR AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2698
Mailing Address - Country:US
Mailing Address - Phone:559-439-6600
Mailing Address - Fax:
Practice Address - Street 1:7525 N CEDAR AVE STE 105
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2698
Practice Address - Country:US
Practice Address - Phone:559-439-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA87859126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant