Provider Demographics
NPI:1770712820
Name:DAVIS, TYSON ARCHER (DDS)
Entity type:Individual
Prefix:DR
First Name:TYSON
Middle Name:ARCHER
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 1:2028 N TREKELL RD # 107-108
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-1326
Mailing Address - Country:US
Mailing Address - Phone:520-876-9955
Mailing Address - Fax:
Practice Address - Street 1:2028 N TREKELL RD STE 107
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-1326
Practice Address - Country:US
Practice Address - Phone:520-876-9955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD78151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice