Basic Information
| Provider Information | |||||||||
| NPI: | 1801838859 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | ALLAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 143 KENNEDY DR | ||||||||
| Address2: | |||||||||
| City: | MARTIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382373309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315875321 | ||||||||
| FaxNumber: | 7315883229 | ||||||||
| Practice Location | |||||||||
| Address1: | 143 KENNEDY DR | ||||||||
| Address2: | |||||||||
| City: | MARTIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382373309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315875321 | ||||||||
| FaxNumber: | 7315883229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 01/03/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 28963 | GA | N | Other Service Providers | Specialist | 208600000X | 46558 | TN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 4277903 | 01 | TN | BCBS | OTHER | 1522027 | 05 | TN | MEDICAID | 010015387 | 01 | GA | RAILROAD MEDICARE | OTHER | 237034DA | 01 | GA | BC/BS | OTHER | 00328391A | 05 | GA | MEDICAID |