Provider Demographics
NPI:1790855575
Name:DAVIS, CHARLES H (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:H
Last Name:DAVIS
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 1:1218 E VENICE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-7151
Mailing Address - Country:US
Mailing Address - Phone:941-488-1075
Mailing Address - Fax:941-484-6277
Practice Address - Street 1:1218 E VENICE AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-7151
Practice Address - Country:US
Practice Address - Phone:941-488-1075
Practice Address - Fax:941-484-6277
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN114341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
U35144Medicare UPIN
63334Medicare ID - Type Unspecified