1477641041 NPI number — DR. GORDON BRUCE DAVIS M.D., D.D.S.

Table of content: DR. GORDON BRUCE DAVIS M.D., D.D.S. (NPI 1477641041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477641041 NPI number — DR. GORDON BRUCE DAVIS M.D., D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
GORDON
Provider Middle Name:
BRUCE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., D.D.S.
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:
1477641041
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9810 MARINE VIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUKILTEO
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98275-4110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-348-1382
Provider Business Mailing Address Fax Number:
425-903-4402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 PACIFIC AVE
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98201-4200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-348-1382
Provider Business Practice Location Address Fax Number:
425-903-4402
Provider Enumeration Date:
10/10/2006

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: 1223S0112X , with the licence number:  4915 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5161 . This is a "WASHINGTON DENTAL SERVICE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 21701 . This is a "DENTAL LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: DE00004915 . This is a "DENTAL LICENSE NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 14666 . This is a "MD LICENSE NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com