Provider Demographics
NPI:1831289099
Name:DAVIDSON, JACK ALLEN JR (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ALLEN
Last Name:DAVIDSON
Suffix:JR
Gender:M
Credentials:DDS, MD
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Mailing Address - Street 1:1165 NIKKI VIEW DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4879
Mailing Address - Country:US
Mailing Address - Phone:813-571-1516
Mailing Address - Fax:813-571-1626
Practice Address - Street 1:1165 NIKKI VIEW DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4879
Practice Address - Country:US
Practice Address - Phone:813-571-1516
Practice Address - Fax:813-571-1626
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2009-04-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MD107941223S0112X
FLME72794208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery