Provider Demographics
NPI:1073027991
Name:DAVIS, BRANDON (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
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 1:1160 VAL VISTA ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-1352
Mailing Address - Country:US
Mailing Address - Phone:818-974-3882
Mailing Address - Fax:
Practice Address - Street 1:767 N HILL ST STE 213
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-2365
Practice Address - Country:US
Practice Address - Phone:213-808-1790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101463122300000X
CADDS101463122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist