Provider Demographics
NPI:1629090659
Name:DAVIDSON, DENA (OD)
Entity Type:Individual
Prefix:DR
First Name:DENA
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 LYNDELL TER
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-6202
Mailing Address - Country:US
Mailing Address - Phone:530-757-6000
Mailing Address - Fax:530-231-5873
Practice Address - Street 1:2035 LYNDELL TER
Practice Address - Street 2:SUITE 100
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-6202
Practice Address - Country:US
Practice Address - Phone:530-757-6000
Practice Address - Fax:530-231-5873
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT10473T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ32043ZMedicare ID - Type Unspecified
U61678Medicare UPIN