Provider Demographics
NPI:1235337080
Name:DAVIS, MARK VINCENT (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:VINCENT
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 1:14010 ROOSEVELT BLVD
Mailing Address - Street 2:SUITE 704
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33762-3862
Mailing Address - Country:US
Mailing Address - Phone:727-531-9363
Mailing Address - Fax:727-535-3720
Practice Address - Street 1:14010 ROOSEVELT BLVD
Practice Address - Street 2:SUITE 704
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33762-3862
Practice Address - Country:US
Practice Address - Phone:727-531-9363
Practice Address - Fax:727-535-3720
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL45491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4549OtherLICENSE NUMBER