Healthcare Provider Details

I. General information

NPI: 1346373347
Provider Name (Legal Business Name): JODY BRIAN VANCE D.D.S, M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3331 E MONTCLAIR ST STE G
SPRINGFIELD MO
65804-4786
US

IV. Provider business mailing address

3331 E MONTCLAIR ST STE G
SPRINGFIELD MO
65804-4786
US

V. Phone/Fax

Practice location:
  • Phone: 417-889-5297
  • Fax: 417-889-6462
Mailing address:
  • Phone: 417-889-5297
  • Fax: 417-889-6462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number015623
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: