Provider Demographics
NPI:1073826996
Name:GORDON B DAVIS MD DDS PS
Entity Type:Organization
Organization Name:GORDON B DAVIS MD DDS PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD DDS
Authorized Official - Phone:425-348-1382
Mailing Address - Street 1:9810 MARINE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-4110
Mailing Address - Country:US
Mailing Address - Phone:425-348-1382
Mailing Address - Fax:425-903-4402
Practice Address - Street 1:1111 PACIFIC AVE
Practice Address - Street 2:SUITE A
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4200
Practice Address - Country:US
Practice Address - Phone:425-258-9586
Practice Address - Fax:425-259-1486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-20
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAA09087Medicare UPIN
WAG001200184Medicare PIN