1982324315 NPI number — MRS. DESIREE MARIE DAVENPORT-DESSUS LMT

Table of content: MRS. DESIREE MARIE DAVENPORT-DESSUS LMT (NPI 1982324315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982324315 NPI number — MRS. DESIREE MARIE DAVENPORT-DESSUS LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVENPORT-DESSUS
Provider First Name:
DESIREE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
N/A
Provider Other First Name:
DMD WELLNESS LLC
Provider Other Middle Name:
N/A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LLC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1982324315
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9104 BOWFIELD DR STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KILLEEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76542-6289
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-688-0460
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 W FM 2410 RD STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARKER HEIGHTS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76548-1806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-519-2273
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2022

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: 225700000X , with the licence number:  MT134278 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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