Provider Demographics
NPI:1841205432
Name:W. J. DAVIS DENTAL ASSOC. OF MCO, INC.
Entity Type:Organization
Organization Name:W. J. DAVIS DENTAL ASSOC. OF MCO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:419-383-4547
Mailing Address - Street 1:25955 WILLOWBEND RD
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-9535
Mailing Address - Country:US
Mailing Address - Phone:419-383-4547
Mailing Address - Fax:419-383-6127
Practice Address - Street 1:3000 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2595
Practice Address - Country:US
Practice Address - Phone:419-383-4547
Practice Address - Fax:419-383-6127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH15900122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0390634Medicaid
OH0390634Medicaid
DA0480301Medicare ID - Type Unspecified