Provider Demographics
NPI:1417006776
Name:DAVIDSON, STEPHEN (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:DAVIDSON
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 1:200 CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-1936
Mailing Address - Country:US
Mailing Address - Phone:406-290-7778
Mailing Address - Fax:406-293-2630
Practice Address - Street 1:200 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-1936
Practice Address - Country:US
Practice Address - Phone:406-293-7778
Practice Address - Fax:406-293-2630
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT18081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice