Provider Demographics
NPI:1306074943
Name:DAVIS, LANCE EDWIN (MD)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:EDWIN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 HANOVER ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-7211
Mailing Address - Country:US
Mailing Address - Phone:214-363-4805
Mailing Address - Fax:
Practice Address - Street 1:3621 HANOVER ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-7211
Practice Address - Country:US
Practice Address - Phone:214-363-4805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP20034594207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology