Provider Demographics
NPI:1790171429
Name:DR. ROBERT C. DAVIS
Entity Type:Organization
Organization Name:DR. ROBERT C. DAVIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:719-542-5300
Mailing Address - Street 1:902 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1159
Mailing Address - Country:US
Mailing Address - Phone:719-542-5300
Mailing Address - Fax:719-545-5525
Practice Address - Street 1:902 WEST 29TH STREET
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1159
Practice Address - Country:US
Practice Address - Phone:719-542-5300
Practice Address - Fax:719-545-5525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3556122300000X
124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO=========OtherTAX ID