Provider Demographics
NPI:1194751545
Name:AGERS, JOHN LEO (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LEO
Last Name:AGERS
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 1:120 BOYD ST
Mailing Address - Street 2:PO BOX 572
Mailing Address - City:DESOTO
Mailing Address - State:MO
Mailing Address - Zip Code:63020-1711
Mailing Address - Country:US
Mailing Address - Phone:636-586-3440
Mailing Address - Fax:636-586-2228
Practice Address - Street 1:120 BOYD ST
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-1711
Practice Address - Country:US
Practice Address - Phone:636-586-3440
Practice Address - Fax:636-586-2228
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO12475122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist