Provider Demographics
NPI:1306092861
Name:DAVIS ORTHODONTICS
Entity type:Organization
Organization Name:DAVIS ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:760-781-1086
Mailing Address - Street 1:400 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-2718
Mailing Address - Country:US
Mailing Address - Phone:760-781-1086
Mailing Address - Fax:760-781-1089
Practice Address - Street 1:400 N BROADWAY
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-2718
Practice Address - Country:US
Practice Address - Phone:760-781-1086
Practice Address - Fax:760-781-1089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295761223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB2957602OtherDENTICAL
CA973179OtherUNITED CONCORDIA