Provider Demographics
NPI:1548403314
Name:JACK A DAVIDSON DDS MD PLLC
Entity Type:Organization
Organization Name:JACK A DAVIDSON DDS MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:813-571-1516
Mailing Address - Street 1:1165 NIKKI VIEW DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4879
Mailing Address - Country:US
Mailing Address - Phone:813-571-1516
Mailing Address - Fax:813-571-1626
Practice Address - Street 1:1165 NIKKI VIEW DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4879
Practice Address - Country:US
Practice Address - Phone:813-571-1516
Practice Address - Fax:813-571-1626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD107941223S0112X
FLME727942086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty