Provider Demographics
NPI:1942212808
Name:DAVISON, RICKY LAWRENCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICKY
Middle Name:LAWRENCE
Last Name:DAVISON
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 1:7520 MONTGOMERY BLVD NE
Mailing Address - Street 2:SUITE E-4
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1521
Mailing Address - Country:US
Mailing Address - Phone:505-883-6111
Mailing Address - Fax:505-883-6101
Practice Address - Street 1:7520 MONTGOMERY BLVD NE
Practice Address - Street 2:SUITE E-4
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1521
Practice Address - Country:US
Practice Address - Phone:505-883-6111
Practice Address - Fax:505-883-6101
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM11141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice