Provider Demographics
NPI:1932282795
Name:PROVORSE, ROBERT C (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:C
Last Name:PROVORSE
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 1:700 HIGHWAY 24 SOUTH
Mailing Address - Street 2:PO BOX 1305
Mailing Address - City:BUENA VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81211-1305
Mailing Address - Country:US
Mailing Address - Phone:719-395-8641
Mailing Address - Fax:
Practice Address - Street 1:700 HIGHWAY 24 SOUTH
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:CO
Practice Address - Zip Code:81211-1305
Practice Address - Country:US
Practice Address - Phone:719-395-8641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1057921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice