Provider Demographics
NPI:1750430955
Name:DAVIS, DARRELL W (DDS, PC)
Entity type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:W
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17020 E US HIGHWAY 40
Mailing Address - Street 2:SUITE #7
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-5361
Mailing Address - Country:US
Mailing Address - Phone:816-350-7710
Mailing Address - Fax:816-350-7711
Practice Address - Street 1:17020 E US HIGHWAY 40
Practice Address - Street 2:SUITE #7
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-5361
Practice Address - Country:US
Practice Address - Phone:816-350-7710
Practice Address - Fax:816-350-7711
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO151361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice