Provider Demographics
NPI:1649351941
Name:DAVIES, DANTAE D (MD)
Entity type:Individual
Prefix:DR
First Name:DANTAE
Middle Name:D
Last Name:DAVIES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 JONES WAY
Mailing Address - Street 2:STE 8
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1217
Mailing Address - Country:US
Mailing Address - Phone:805-577-7977
Mailing Address - Fax:805-577-0745
Practice Address - Street 1:2650 JONES WAY
Practice Address - Street 2:STE 8
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1217
Practice Address - Country:US
Practice Address - Phone:805-577-7977
Practice Address - Fax:805-577-0745
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG28898208600000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G288980Medicaid
G28898BMedicare ID - Type Unspecified
CA00G288980Medicaid