Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 2739 | AZ |
NPI | 1053355214 |
---|---|
Provider Name | Leslie I Davis |
First Address | Sun City West, AZ 85375-4486 |
Second Address | Sun City West, AZ 85375-4486 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/06/2006 |
Last Update Date | 15/03/2010 |