Provider Demographics
NPI:1144391855
Name:DAVIS, LORETTA
Entity Type:Individual
Prefix:DR
First Name:LORETTA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 S RANDALL RD STE 102
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-4110
Mailing Address - Country:US
Mailing Address - Phone:477-170-4148
Mailing Address - Fax:
Practice Address - Street 1:1190 S RANDALL RD STE 102
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4110
Practice Address - Country:US
Practice Address - Phone:477-170-4148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0244681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice