Provider Demographics
NPI:1720447147
Name:DR. MONICA A. DAVENPORT, DDS APC
Entity type:Organization
Organization Name:DR. MONICA A. DAVENPORT, DDS APC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-226-0244
Mailing Address - Street 1:1850 MARTIN LUTHER KING DR.
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-5020
Mailing Address - Country:US
Mailing Address - Phone:318-226-0244
Mailing Address - Fax:318-226-0282
Practice Address - Street 1:1850 MARTIN LUTHER KING DR.
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-5020
Practice Address - Country:US
Practice Address - Phone:318-226-0244
Practice Address - Fax:318-226-0282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-12
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA50011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1850012Medicaid