Provider Demographics
NPI:1942389937
Name:DAVIDSON, GREGG R (DDS)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:R
Last Name:DAVIDSON
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 1:6600 MERCY CT STE 200
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-3198
Mailing Address - Country:US
Mailing Address - Phone:916-966-6060
Mailing Address - Fax:916-966-1330
Practice Address - Street 1:6600 MERCY CT STE 200
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-3198
Practice Address - Country:US
Practice Address - Phone:916-966-6060
Practice Address - Fax:916-966-1330
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA305291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA30529OtherLICENSE NUMBER