Provider Demographics
NPI:1699960039
Name:DAVIS, GREG RON (DDS)
Entity type:Individual
Prefix:DR
First Name:GREG
Middle Name:RON
Last Name:DAVIS
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 1:467 S RIVERSHORE LN
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4978
Mailing Address - Country:US
Mailing Address - Phone:208-939-9235
Mailing Address - Fax:208-939-9235
Practice Address - Street 1:467 S RIVERSHORE LN
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4978
Practice Address - Country:US
Practice Address - Phone:208-939-9235
Practice Address - Fax:208-939-9235
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3175122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist