Provider Demographics
NPI:1144308065
Name:DAVIS, CHARLES ROSA (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ROSA
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 1:4500 I 55 NORTH
Mailing Address - Street 2:238 HIGHLAND VILLAGE
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211
Mailing Address - Country:US
Mailing Address - Phone:601-981-7200
Mailing Address - Fax:601-981-6832
Practice Address - Street 1:4500 I 55 NORTH
Practice Address - Street 2:238 HIGHLAND VILLAGE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211
Practice Address - Country:US
Practice Address - Phone:601-981-7200
Practice Address - Fax:601-981-6832
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS94759122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist