Provider Demographics
NPI:1235377219
Name:DAVIS EAGLIN, KESIA NICHOLE (RDA)
Entity Type:Individual
Prefix:MRS
First Name:KESIA
Middle Name:NICHOLE
Last Name:DAVIS EAGLIN
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2483 BUNCHE PL
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-5710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2483 BUNCHE PL
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-5710
Practice Address - Country:US
Practice Address - Phone:951-536-6841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-28
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69704126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant