Provider Demographics
NPI:1083009203
Name:DAVIDSON, MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 CENTRAL AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3025
Mailing Address - Country:US
Mailing Address - Phone:973-744-9330
Mailing Address - Fax:
Practice Address - Street 1:148 CENTRAL AVE FL 1
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3025
Practice Address - Country:US
Practice Address - Phone:973-744-9330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-03
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI026217001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice