1730197849 NPI number — DR. JEFFREY K DAVIS DDS

Table of content: DR. JEFFREY K DAVIS DDS (NPI 1730197849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730197849 NPI number — DR. JEFFREY K DAVIS DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
JEFFREY
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730197849
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2015 N LOCUST GROVE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-1827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-888-1802
Provider Business Mailing Address Fax Number:
208-887-3908

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2015 N LOCUST GROVE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-1827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-888-1802
Provider Business Practice Location Address Fax Number:
208-887-3908
Provider Enumeration Date:
08/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  N-01893 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1615855 . This is a "UNITED CONCORDIA INS." identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 6O183 (LETTER O) . This is a "BLUE CROSS OF IDAHO INS." identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: CS10530 . This is a "ID STATE BOARD OF PHARM" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: N-01893 . This is a "ID STATE BOARD OF DENTIST" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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