Provider Demographics
NPI:1699976126
Name:DAVENPORT, GREGORY ALAN (DDS)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALAN
Last Name:DAVENPORT
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 1:277 S HIGH ST
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-1461
Mailing Address - Country:US
Mailing Address - Phone:330-638-7796
Mailing Address - Fax:330-637-5218
Practice Address - Street 1:277 S HIGH ST
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-1461
Practice Address - Country:US
Practice Address - Phone:330-638-7796
Practice Address - Fax:330-637-5218
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH148291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice