Provider Demographics
NPI:1700832458
Name:DAVENPORT, MAYNARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAYNARD
Middle Name:
Last Name:DAVENPORT
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:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-0368
Mailing Address - Country:US
Mailing Address - Phone:928-367-3543
Mailing Address - Fax:928-367-2084
Practice Address - Street 1:43 W WHITE MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:PINETOP
Practice Address - State:AZ
Practice Address - Zip Code:85935-7060
Practice Address - Country:US
Practice Address - Phone:928-367-3543
Practice Address - Fax:928-367-2084
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD10861223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics