Provider Demographics
NPI:1801332127
Name:DAVIS, EDWARD MITCHELL JR (DDS)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:MITCHELL
Last Name:DAVIS
Suffix:JR
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 1:1865 KNIGHTS FERRY DR
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 CARLSBAD VILLAGE DR
Practice Address - Street 2:SUITE 203
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2900
Practice Address - Country:US
Practice Address - Phone:760-487-0203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101113122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist