Basic Information
| Provider Information | |||||||||
| NPI: | 1225057029 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | RANCE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4016 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CASSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656259753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178470057 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4016 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CASSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656259753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178470057 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | 07/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 19572 | TX | N | Dental Providers | Dentist | General Practice | 1223D0001X | 2020022988 | MO | Y | Dental Providers | Dentist | Dental Public Health |
ID Information
| ID | Type | State | Issuer | Description | 19572 | 01 | TX | STATE LICENSE | OTHER | 2020022988 | 01 | MO | STATE LICENSE | OTHER | 752849726 | 01 | TAX ID | OTHER |