Provider Demographics
NPI:1306839162
Name:DAVIS, MARK HOWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:HOWARD
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 1:8390 CHAMPIONS GATE BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:CHAMPIONS GATE
Mailing Address - State:FL
Mailing Address - Zip Code:33896-8310
Mailing Address - Country:US
Mailing Address - Phone:407-390-1677
Mailing Address - Fax:407-390-1765
Practice Address - Street 1:1414 S GRAND AVE
Practice Address - Street 2:SUITE 485
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3076
Practice Address - Country:US
Practice Address - Phone:213-744-1752
Practice Address - Fax:213-744-1753
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44469122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG91674-01OtherDENTI-CAL