John R Provenzano DDS,PA

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

6557 Issued in KS

Legal business name

JOHN R PROVENZANO DDS,PA

Practice address

1515 S Clifton Ave Ste 120
Wichita, KS 67218-2951

Phone

(316) 681-3757

Fax

(316) 652-0602

NPI assigned

Jan 12, 2012

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

John R Provenzano, DDS,PA

Title

Owner

Phone

(316) 681-3757

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1326326400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1328745600000",
    "number": "1639449259",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1515 S CLIFTON AVE STE 120",
            "city": "WICHITA",
            "state": "KS",
            "postal_code": "672182951",
            "telephone_number": "316-681-3757",
            "fax_number": "316-652-0602"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1515 S CLIFTON AVE STE 120",
            "city": "WICHITA",
            "state": "KS",
            "postal_code": "672182951",
            "telephone_number": "316-681-3757",
            "fax_number": "316-652-0602"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JOHN R PROVENZANO DDS,PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-01-12",
        "last_updated": "2012-02-09",
        "status": "A",
        "authorized_official_last_name": "PROVENZANO",
        "authorized_official_first_name": "JOHN",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "316-681-3757",
        "authorized_official_credential": "DDS,PA"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "KS",
            "license": "6557",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE P-TAN",
            "identifier": "019243",
            "state": "KS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Oral and Maxillofacial Surgery (Dentist) in Wichita, KS
• Providers in Wichita, KS by specialty
• Oral and Maxillofacial Surgery (Dentist) in Kansas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 9, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.