Provider Demographics
NPI:1295872117
Name:DAVIS, GREGORY S (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:S
Last Name:DAVIS
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:PO BOX 297
Mailing Address - Street 2:
Mailing Address - City:KAUNAKAKAI
Mailing Address - State:HI
Mailing Address - Zip Code:96748-0297
Mailing Address - Country:US
Mailing Address - Phone:808-553-3254
Mailing Address - Fax:808-553-3006
Practice Address - Street 1:10 MOHALA STREET
Practice Address - Street 2:SUITE 5
Practice Address - City:KAUNAKAKAI
Practice Address - State:HI
Practice Address - Zip Code:96748
Practice Address - Country:US
Practice Address - Phone:808-553-3254
Practice Address - Fax:808-553-3006
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI8941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI06714301Medicaid