Provider Demographics
NPI:1275833485
Name:DAVIS, JEANNIE M
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 2ND STREET
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ND
Mailing Address - Zip Code:58472-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 2ND STREET
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ND
Practice Address - Zip Code:58472-0001
Practice Address - Country:US
Practice Address - Phone:701-251-3096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA123456124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist