Provider Demographics
NPI:1508214982
Name:G. MICHAEL DAVIS DDS LLC
Entity Type:Organization
Organization Name:G. MICHAEL DAVIS DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:G MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-649-6451
Mailing Address - Street 1:7915 HIGHWAY 165
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:LA
Mailing Address - Zip Code:71418-3327
Mailing Address - Country:US
Mailing Address - Phone:318-649-6451
Mailing Address - Fax:
Practice Address - Street 1:7915 HIGHWAY 165
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:LA
Practice Address - Zip Code:71418-3327
Practice Address - Country:US
Practice Address - Phone:318-649-6451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA33881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1833886Medicaid