Basic Information
| Provider Information | |||||||||
| NPI: | 1346841624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 148 CEDAR WOODS TRL | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301149793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708811993 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1425 RIVERSTONE PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301145611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704790600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2020 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN016157-T | GA | Y | Dental Providers | Dentist | General Practice |
No ID Information.