Provider Demographics
NPI:1013924349
Name:DAVIDSON, GEORGE W (DMD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:W
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3504 E MARIA DR
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-1334
Mailing Address - Country:US
Mailing Address - Phone:715-342-8060
Mailing Address - Fax:715-342-0062
Practice Address - Street 1:3504 E MARIA DR
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-1334
Practice Address - Country:US
Practice Address - Phone:715-342-8060
Practice Address - Fax:715-342-0062
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5419-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33770600Medicaid