Provider Demographics
NPI:1114003597
Name:DAVIS, JERRY ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ROBERT
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 1:494 S EMERSON AVE
Mailing Address - Street 2:SUITE K
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1912
Mailing Address - Country:US
Mailing Address - Phone:317-882-2880
Mailing Address - Fax:317-882-2544
Practice Address - Street 1:494 S EMERSON AVE
Practice Address - Street 2:SUITE K
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1912
Practice Address - Country:US
Practice Address - Phone:317-882-2880
Practice Address - Fax:317-882-2544
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN75951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice