Provider Demographics
NPI:1811981954
Name:DAVIDSON, JEREMY BLAZE (DDS)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:BLAZE
Last Name:DAVIDSON
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 1:857 BISHOPSGATE LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-6181
Mailing Address - Country:US
Mailing Address - Phone:210-837-0716
Mailing Address - Fax:
Practice Address - Street 1:401 N GREAT NECK RD STE 122
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-4063
Practice Address - Country:US
Practice Address - Phone:757-962-2499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014124491223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty