Provider Demographics
NPI:1477641041
Name:DAVIS, GORDON BRUCE (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:BRUCE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9810 MARINE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-4110
Mailing Address - Country:US
Mailing Address - Phone:425-348-1382
Mailing Address - Fax:425-903-4402
Practice Address - Street 1:1111 PACIFIC AVE
Practice Address - Street 2:STE 1
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4200
Practice Address - Country:US
Practice Address - Phone:425-348-1382
Practice Address - Fax:425-903-4402
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA49151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5161OtherWASHINGTON DENTAL SERVICE
CA21701OtherDENTAL LICENSE NUMBER
WADE00004915OtherDENTAL LICENSE NUMBER
WA14666OtherMD LICENSE NUMBER
WADE00004915OtherDENTAL LICENSE NUMBER
WA5161OtherWASHINGTON DENTAL SERVICE