1306839329 NPI number — DR. NELSON CHARLES DAVIS DDS

Table of content: DR. NELSON CHARLES DAVIS DDS (NPI 1306839329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306839329 NPI number — DR. NELSON CHARLES DAVIS DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
NELSON
Provider Middle Name:
CHARLES
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:
1306839329
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
710 S ROYAL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22314-4310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-549-4382
Provider Business Mailing Address Fax Number:
703-692-6123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PENTAGON TRISERVICE DENTAL CLINIC
Provider Second Line Business Practice Location Address:
5802 ARMY PENTAGON
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20310-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-692-8700
Provider Business Practice Location Address Fax Number:
703-692-6123
Provider Enumeration Date:
08/24/2005

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:  DEN 4901 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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