Provider Demographics
NPI:1992307995
Name:DAVENPORT, ELIZABETH CORENE (RDH)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CORENE
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 TALISMAN DR UNIT D4
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-9171
Mailing Address - Country:US
Mailing Address - Phone:970-585-4424
Mailing Address - Fax:
Practice Address - Street 1:190 TALISMAN DR UNIT D4
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-9171
Practice Address - Country:US
Practice Address - Phone:970-585-4424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.000906617124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist