Provider Demographics
NPI:1164620597
Name:DAVIS, GARY S (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:S
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 1:27758 SANTA MARGARITA PKWY
Mailing Address - Street 2:SUITE#334
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 E THOMAS RD
Practice Address - Street 2:SUITE 204
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7646
Practice Address - Country:US
Practice Address - Phone:602-253-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52166122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ383787Medicaid