Provider Demographics
NPI:1811335854
Name:DAVIS, DEAN
Entity type:Individual
Prefix:MR
First Name:DEAN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KENNETH
Other - Middle Name:DEAN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3226 8TH ST APT J
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4836
Mailing Address - Country:US
Mailing Address - Phone:208-305-1964
Mailing Address - Fax:
Practice Address - Street 1:3226 8TH ST APT J
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4836
Practice Address - Country:US
Practice Address - Phone:208-305-1964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID06357783225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist