Provider Demographics
NPI:1033649850
Name:DAVIS, MELISSA LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:LYNN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E. ARMSTRONG AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603
Mailing Address - Country:US
Mailing Address - Phone:847-530-8975
Mailing Address - Fax:
Practice Address - Street 1:6226 14TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-4413
Practice Address - Country:US
Practice Address - Phone:262-656-0044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL390200000X
WI10020381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1002038-15OtherLICENSE
123456789OtherDENTIST