Provider Demographics
NPI:1750762555
Name:PROVO, ALEX
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:PROVO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18185 PARK DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-7977
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MN
Practice Address - Zip Code:56510-1354
Practice Address - Country:US
Practice Address - Phone:218-784-7119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13521122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist