Provider Demographics
NPI:1548415433
Name:DAVIS, JOHN JACKSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JACKSON
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 1:6112 PETERS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-4028
Mailing Address - Country:US
Mailing Address - Phone:540-563-1660
Mailing Address - Fax:
Practice Address - Street 1:23 FAYETTE ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-2703
Practice Address - Country:US
Practice Address - Phone:276-632-7727
Practice Address - Fax:276-632-4397
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-19
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010067821223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry