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General NPI Number Information
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NPI Number | 1346373347
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Entity Type | Individual
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Provider Name | JODY BRIAN VANCE D.D.S, M.S.
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Gender | Male
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Dates
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Enumeration Date | 03/13/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3331 E MONTCLAIR ST STE G
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City | SPRINGFIELD
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State | MO
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Zip | 65804-4786
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Country | US
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Telephone | 417-889-5297
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Fax | 417-889-6462
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Provider Business Mailing Address
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Address Line | 3331 E MONTCLAIR ST STE G
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City | SPRINGFIELD
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State | MO
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Zip | 65804-4786
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Country | US
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Telephone | 417-889-5297
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Fax | 417-889-6462
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 015623
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License Number State | MO
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