Provider Demographics
NPI:1558506428
Name:PAVENTY, ANTHONY (DMD, MS)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:PAVENTY
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2434 NW PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3991
Mailing Address - Country:US
Mailing Address - Phone:541-758-3104
Mailing Address - Fax:
Practice Address - Street 1:2434 NW PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3991
Practice Address - Country:US
Practice Address - Phone:541-758-3104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD92091223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics