Provider Demographics
NPI:1225030828
Name:DEVRIES, JOHN PROCTOR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PROCTOR
Last Name:DEVRIES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANDENBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40108-1002
Mailing Address - Country:US
Mailing Address - Phone:270-422-1181
Mailing Address - Fax:270-422-7834
Practice Address - Street 1:415 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANDENBURG
Practice Address - State:KY
Practice Address - Zip Code:40108-1002
Practice Address - Country:US
Practice Address - Phone:270-422-1181
Practice Address - Fax:270-422-7834
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY67891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice