Provider Demographics
NPI:1235176009
Name:DAVIDSON, MICHAEL J (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
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 1:4770 SUNRISE HWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-2911
Mailing Address - Country:US
Mailing Address - Phone:516-541-1831
Mailing Address - Fax:
Practice Address - Street 1:4770 SUNRISE HWY
Practice Address - Street 2:SUITE 102
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-2911
Practice Address - Country:US
Practice Address - Phone:516-541-1831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice