Provider Demographics
NPI:1114077872
Name:DAVIS, ROBERT A (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:DAVIS
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 1:265 3RD ST
Mailing Address - Street 2:PO BOX 265
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009-2350
Mailing Address - Country:US
Mailing Address - Phone:724-774-1920
Mailing Address - Fax:724-774-3332
Practice Address - Street 1:265 3RD ST
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-2350
Practice Address - Country:US
Practice Address - Phone:724-774-1920
Practice Address - Fax:724-774-3332
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-025969L1223P0221X
OH30-02-02581223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2007689Medicaid
PA0011644380001Medicaid