Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 019029333 | IL |
N | 122300000X | Dentist | DEN.00202313 | CO |
Y | 1223P0221X | Pediatric Dentist | D11447 | OR |
N | 1223P0221X | Pediatric Dentist | DE60650351 | WA |
NPI | 1063787497 |
---|---|
Provider Name | Dustin Michael Davis |
First Address | Clackamas, OR 97015-9356 |
Second Address | Clackamas, OR 97015-9356 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/03/2012 |
Last Update Date | 30/06/2021 |