Provider Demographics
NPI:1396916649
Name:DAVIS, RYAN JAMES (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:JAMES
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 W CANDLETREE DR STE A
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1592
Mailing Address - Country:US
Mailing Address - Phone:309-360-8502
Mailing Address - Fax:
Practice Address - Street 1:1717 W CANDLETREE DR STE A
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1592
Practice Address - Country:US
Practice Address - Phone:309-360-8502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-14
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.027.427122300000X
IL021.0023571223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist