Provider Demographics
NPI:1447351614
Name:DAVIS, MARK LEONARD (DDS)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:LEONARD
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6495 N. PALM AVE STE #105
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704
Mailing Address - Country:US
Mailing Address - Phone:559-277-3001
Mailing Address - Fax:559-277-3031
Practice Address - Street 1:6495 N. PALM AVE STE #105
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93704
Practice Address - Country:US
Practice Address - Phone:559-277-3001
Practice Address - Fax:559-277-3031
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA360751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA770204959OtherTAX ID