Provider Demographics
NPI:1790766483
Name:EMELINE T. DAVIS
Entity Type:Organization
Organization Name:EMELINE T. DAVIS
Other - Org Name:ADVANCED DENTAL LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:EMELINE
Authorized Official - Middle Name:T
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-232-4664
Mailing Address - Street 1:2955 PROFESSIONAL LN
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-3300
Mailing Address - Country:US
Mailing Address - Phone:812-232-4664
Mailing Address - Fax:812-234-5427
Practice Address - Street 1:2955 PROFESSIONAL LN
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3300
Practice Address - Country:US
Practice Address - Phone:812-232-4664
Practice Address - Fax:812-234-5427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008723122300000X
IN12009834122300000X
IN12010103122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100251550AMedicaid