Provider Demographics
NPI:1184931222
Name:DAVIS, JOHN CHARLES (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
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 1:3001A 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GREAT LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60088
Mailing Address - Country:US
Mailing Address - Phone:847-688-2755
Mailing Address - Fax:847-688-2546
Practice Address - Street 1:3001A 6TH ST
Practice Address - Street 2:
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088
Practice Address - Country:US
Practice Address - Phone:847-688-2755
Practice Address - Fax:847-688-2546
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA599371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program