Provider Demographics
NPI:1851514459
Name:DAVIS, MARK L (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
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 1:901 OAK PARK BLVD STE 201
Mailing Address - Street 2:1
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3410
Mailing Address - Country:US
Mailing Address - Phone:805-489-5545
Mailing Address - Fax:
Practice Address - Street 1:901 OAK PARK BLVD STE 201
Practice Address - Street 2:1
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3410
Practice Address - Country:US
Practice Address - Phone:805-489-5545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45-5181802122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1851514459OtherDENTAL
WA8141OtherLICENSE NUMBER