Provider Demographics
NPI:1215983994
Name:DAVIDSON, JEFFREY ALLEN (DDS)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALLEN
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 1:18601 VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:92316-1831
Mailing Address - Country:US
Mailing Address - Phone:909-746-0804
Mailing Address - Fax:
Practice Address - Street 1:18601 VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:CA
Practice Address - Zip Code:92316-1831
Practice Address - Country:US
Practice Address - Phone:909-746-0804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54496122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist