Provider Demographics
NPI:1700148004
Name:CHARLES A DAVIS DDS MS PC
Entity Type:Organization
Organization Name:CHARLES A DAVIS DDS MS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:520-326-8516
Mailing Address - Street 1:716 N COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-4506
Mailing Address - Country:US
Mailing Address - Phone:520-326-8516
Mailing Address - Fax:520-326-1013
Practice Address - Street 1:716 N COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-4506
Practice Address - Country:US
Practice Address - Phone:520-326-8516
Practice Address - Fax:520-326-1013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18811223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ082868Medicaid