Provider Demographics
NPI:1306839329
Name:DAVIS, NELSON CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:NELSON
Middle Name:CHARLES
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 1:710 S ROYAL ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-4310
Mailing Address - Country:US
Mailing Address - Phone:703-549-4382
Mailing Address - Fax:703-692-6123
Practice Address - Street 1:PENTAGON TRISERVICE DENTAL CLINIC
Practice Address - Street 2:5802 ARMY PENTAGON
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20310-0001
Practice Address - Country:US
Practice Address - Phone:703-692-8700
Practice Address - Fax:703-692-6123
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN 49011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice