| John R Provenzano Dds,pa | |
|
1515 S Clifton Ave Ste 120 Wichita KS 67218-2951 | |
| (316) 681-3757 | |
| (316) 652-0602 |
| Full Name | John R Provenzano Dds,pa |
|---|---|
| Speciality | Dentist - Oral And Maxillofacial Surgery |
| Location | 1515 S Clifton Ave Ste 120, Wichita, Kansas |
| Authorized Official Name and Position | John R Provenzano (OWNER) |
| Authorized Official Contact | 3166813757 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| John R Provenzano Dds,pa 1515 S Clifton Ave Ste 120 Wichita KS 67218-2951 Ph: (316) 681-3757 | John R Provenzano Dds,pa 1515 S Clifton Ave Ste 120 Wichita KS 67218-2951 Ph: (316) 681-3757 |
| NPI Number | 1639449259 |
|---|---|
| Provider Enumeration Date | 01/12/2012 |
| Last Update Date | 02/09/2012 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1639449259 | NPI | - | NPPES |
| 019243 | Other | KS | MEDICARE P-TAN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223S0112X | Dentist - Oral And Maxillofacial Surgery | 6557 (Kansas) | Primary |
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