Provider Demographics
NPI:1922457746
Name:COSTES DAVIS, DDS DENTAL PRACTICE
Entity Type:Organization
Organization Name:COSTES DAVIS, DDS DENTAL PRACTICE
Other - Org Name:HALL OF FAME DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING/INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELCIE
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-925-6522
Mailing Address - Street 1:3015 CALLOWAY DR UNIT 14
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93312-2659
Mailing Address - Country:US
Mailing Address - Phone:661-587-6453
Mailing Address - Fax:
Practice Address - Street 1:3015 CALLOWAY DR UNIT 14
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93312-2659
Practice Address - Country:US
Practice Address - Phone:661-587-6453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty