Provider Demographics
NPI:1992940803
Name:DAVIS, PAUL FREDERIC (DDS)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:FREDERIC
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:PAUL
Other - Middle Name:FREDERIC
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 765
Mailing Address - Street 2:
Mailing Address - City:LOON LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99148-0765
Mailing Address - Country:US
Mailing Address - Phone:509-233-9074
Mailing Address - Fax:
Practice Address - Street 1:40217 NORTH SHORE DR.
Practice Address - Street 2:
Practice Address - City:LOON LAKE
Practice Address - State:WA
Practice Address - Zip Code:99148-0765
Practice Address - Country:US
Practice Address - Phone:509-233-9074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-05
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00005119122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5546205Medicaid