Provider Demographics
NPI:1801963319
Name:DAVIS, GERRAD DEWAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:GERRAD
Middle Name:DEWAYNE
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 1:1309 JACKIE RD
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-1566
Mailing Address - Country:US
Mailing Address - Phone:580-255-3570
Mailing Address - Fax:580-255-5015
Practice Address - Street 1:1309 JACKIE RD
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-1566
Practice Address - Country:US
Practice Address - Phone:580-255-3570
Practice Address - Fax:580-255-5015
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK58501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1801963319Medicaid
OK1164500328Medicaid