Provider Demographics
NPI:1710955430
Name:PROVENZANO, JOHN R (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:PROVENZANO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1515 S CLIFTON AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-2900
Mailing Address - Country:US
Mailing Address - Phone:316-681-3757
Mailing Address - Fax:316-652-0602
Practice Address - Street 1:1515 S CLIFTON AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-2900
Practice Address - Country:US
Practice Address - Phone:316-681-3757
Practice Address - Fax:316-652-0602
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS65571223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS00019243Medicare ID - Type Unspecified