Provider Demographics
NPI:1780218511
Name:DAVIS, MICHAEL R (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
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 1:2400 COLONY CROSSING PL
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4281
Mailing Address - Country:US
Mailing Address - Phone:727-623-8077
Mailing Address - Fax:
Practice Address - Street 1:2400 COLONY CROSSING PL
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4281
Practice Address - Country:US
Practice Address - Phone:727-623-8077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0263991223P0221X
VA04014177791223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0439315Medicaid