Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 2455 | AR |
NPI | 1588778641 |
---|---|
Provider Name | Dr. Mark A, Davis |
First Address | Shirley, AR 72153-8930 |
Second Address | Shirley, AR 72153-8930 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2006 |
Last Update Date | 08/07/2007 |