Provider Demographics
NPI:1477656668
Name:DAVIS, GERALD WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:WAYNE
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 1:356 E VIRGINIA AVE
Mailing Address - Street 2:P. O. BOX 824
Mailing Address - City:VINTON
Mailing Address - State:VA
Mailing Address - Zip Code:24179-3405
Mailing Address - Country:US
Mailing Address - Phone:540-344-7222
Mailing Address - Fax:540-344-6631
Practice Address - Street 1:356 E VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:VA
Practice Address - Zip Code:24179-3405
Practice Address - Country:US
Practice Address - Phone:540-344-7222
Practice Address - Fax:540-344-6631
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010049951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT21467Medicare UPIN