Provider Demographics
NPI:1073592697
Name:DAVIS, SAMUEL (DDS)
Entity Type:Individual
Prefix:
First Name:SAMUEL
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 1:4075 SAINT CROIX DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-9123
Mailing Address - Country:US
Mailing Address - Phone:405-348-8779
Mailing Address - Fax:405-348-8779
Practice Address - Street 1:RANDOLPH ROAD
Practice Address - Street 2:COWAN DENTAL CLINIC BLDG 605
Practice Address - City:FT. SILL
Practice Address - State:OK
Practice Address - Zip Code:73503
Practice Address - Country:US
Practice Address - Phone:580-442-5925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice