Provider Demographics
NPI:1639449259
Name:JOHN R PROVENZANO DDS,PA
Entity Type:Organization
Organization Name:JOHN R PROVENZANO DDS,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:PROVENZANO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,PA
Authorized Official - Phone:316-681-3757
Mailing Address - Street 1:1515 S CLIFTON AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-2951
Mailing Address - Country:US
Mailing Address - Phone:316-681-3757
Mailing Address - Fax:316-652-0602
Practice Address - Street 1:1515 S CLIFTON AVE STE 120
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-2951
Practice Address - Country:US
Practice Address - Phone:316-681-3757
Practice Address - Fax:316-652-0602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS65571223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS019243OtherMEDICARE P-TAN