Provider Demographics
NPI:1861647604
Name:DAVIS DENTAL GROUP
Entity Type:Organization
Organization Name:DAVIS DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-537-9317
Mailing Address - Street 1:113 132ND ST S
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-4807
Mailing Address - Country:US
Mailing Address - Phone:253-537-9317
Mailing Address - Fax:253-537-1371
Practice Address - Street 1:113 132ND ST S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-4807
Practice Address - Country:US
Practice Address - Phone:253-537-9317
Practice Address - Fax:253-537-1371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-20
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA9916122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty