Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | 56519 | MN |
N | 204E00000X | Oral & Maxillofacial Surgeon | D12742 | MN |
NPI | 1457583742 |
---|---|
Provider Name | Stephen Matthew Davis |
First Address | Rochester, MN 55905-0001 |
Second Address | Rochester, MN 55905-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/08/2009 |
Last Update Date | 16/10/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
ENROLLED | (05) | MN |