Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 6734 | OK |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 61536 | KS |
NPI | 1134505399 |
---|---|
Provider Name | Dr. Myles Davidson |
First Address | Wichita, KS 67205-1226 |
Second Address | Wichita, KS 67205 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/08/2015 |
Last Update Date | 12/11/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
61536 | KANSAS DENTAL LICNESE (01) | KS |
6734 | DENTAL LICENSE NUMBER (01) | OK |