Provider Demographics
NPI:1740224435
Name:DAVENPORT, MONICA ANNETTE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MONICA
Middle Name:ANNETTE
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 MARTIN LUTHER KING DR.
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-5020
Mailing Address - Country:US
Mailing Address - Phone:318-226-0244
Mailing Address - Fax:318-226-0282
Practice Address - Street 1:1850 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-5020
Practice Address - Country:US
Practice Address - Phone:318-226-0244
Practice Address - Fax:318-226-0282
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5001122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5001Medicaid