Provider Demographics
NPI:1396271615
Name:DAVIS, CHARMAINE
Entity type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2070 E 57TH ST
Mailing Address - Street 2:2 ND FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4702
Mailing Address - Country:US
Mailing Address - Phone:917-698-5479
Mailing Address - Fax:
Practice Address - Street 1:2070 E 57TH ST
Practice Address - Street 2:2 ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4702
Practice Address - Country:US
Practice Address - Phone:718-251-1886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0239951124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist