Provider Demographics
NPI:1952689937
Name:DAVIS DENTAL PC
Entity Type:Organization
Organization Name:DAVIS DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:THOMASSON
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-634-3488
Mailing Address - Street 1:3116 ACACIA DR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-5804
Mailing Address - Country:US
Mailing Address - Phone:307-634-3488
Mailing Address - Fax:
Practice Address - Street 1:3116 ACACIA DR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5804
Practice Address - Country:US
Practice Address - Phone:307-634-3488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1275122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty