Provider Demographics
NPI: | 1558660498 |
---|---|
Name: | DAVIS ENT SPECIALISTS, PC |
Entity Type: | Organization |
Organization Name: | DAVIS ENT SPECIALISTS, PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER/MD |
Authorized Official - Prefix: | |
Authorized Official - First Name: | THOMAS |
Authorized Official - Middle Name: | C |
Authorized Official - Last Name: | DAVIS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 307-686-7346 |
Mailing Address - Street 1: | 407 S MEDICAL ARTS CT |
Mailing Address - Street 2: | STE. C |
Mailing Address - City: | GILLETTE |
Mailing Address - State: | WY |
Mailing Address - Zip Code: | 82716-3372 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 307-686-7346 |
Mailing Address - Fax: | 307-682-1485 |
Practice Address - Street 1: | 407 S MEDICAL ARTS CT |
Practice Address - Street 2: | STE. C |
Practice Address - City: | GILLETTE |
Practice Address - State: | WY |
Practice Address - Zip Code: | 82716-3372 |
Practice Address - Country: | US |
Practice Address - Phone: | 307-686-7346 |
Practice Address - Fax: | 307-682-1485 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-03-17 |
Last Update Date: | 2011-03-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WY | 7762A | 332B00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies |