Provider Demographics
NPI:1457407744
Name:PURVIANCE, KEVIN (DMD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:PURVIANCE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 SOUTH MAIN SREET
Mailing Address - Street 2:301
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1944
Mailing Address - Country:US
Mailing Address - Phone:860-236-2566
Mailing Address - Fax:860-236-2282
Practice Address - Street 1:61 SOUTH MAIN SREET
Practice Address - Street 2:301
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1944
Practice Address - Country:US
Practice Address - Phone:860-236-2566
Practice Address - Fax:860-236-2282
Is Sole Proprietor?:No
Enumeration Date:2007-01-27
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT93131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice