Provider Demographics
NPI:1316025281
Name:DAVIS, LARRY G (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:G
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 1:370 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ASHDOWN
Mailing Address - State:AR
Mailing Address - Zip Code:71822-2750
Mailing Address - Country:US
Mailing Address - Phone:870-898-5077
Mailing Address - Fax:870-898-2070
Practice Address - Street 1:370 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ASHDOWN
Practice Address - State:AR
Practice Address - Zip Code:71822-2750
Practice Address - Country:US
Practice Address - Phone:870-898-5077
Practice Address - Fax:870-898-2070
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR21841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR468504OtherUNITED CONCORDIA
AR58163OtherBCBS