Provider Demographics
NPI:1083971212
Name:KEVIN PURVIANCE DMD LLC
Entity Type:Organization
Organization Name:KEVIN PURVIANCE DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PURVIANCE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:860-256-2566
Mailing Address - Street 1:61 S MAIN ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2486
Mailing Address - Country:US
Mailing Address - Phone:860-236-2566
Mailing Address - Fax:860-236-2282
Practice Address - Street 1:61 S MAIN ST
Practice Address - Street 2:SUITE 301
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2486
Practice Address - Country:US
Practice Address - Phone:860-236-2566
Practice Address - Fax:860-236-2282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9313261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental