Provider Demographics
NPI:1255489621
Name:DAVIS, THOMAS L JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:L
Last Name:DAVIS
Suffix:JR
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 1:410 E ELLENDALE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-3052
Mailing Address - Country:US
Mailing Address - Phone:503-623-2653
Mailing Address - Fax:
Practice Address - Street 1:410 E ELLENDALE AVE STE 2
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-3052
Practice Address - Country:US
Practice Address - Phone:503-623-2653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR54261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice