Provider Demographics
NPI:1578213161
Name:DAVIS, ERIC CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:CHRISTOPHER
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:638 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:APALACHIN
Mailing Address - State:NY
Mailing Address - Zip Code:13732-2504
Mailing Address - Country:US
Mailing Address - Phone:607-621-5627
Mailing Address - Fax:
Practice Address - Street 1:811 W WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5123
Practice Address - Country:US
Practice Address - Phone:146-187-1773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0653211223G0001X
IL019.0335961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice