# JOHN R PROVENZANO DDS,PA

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1639449259
- **Authorized official:** JOHN R PROVENZANO DDS,PA (OWNER)
- **Authorized official phone:** (316) 681-3757

## Contact information

- **Practice address:** 1515 S CLIFTON AVE STE 120, WICHITA, KS 67218-2951
- **Practice address phone:** (316) 681-3757
- **Practice address fax:** (316) 652-0602
- **Mailing address:** 1515 S CLIFTON AVE STE 120, WICHITA, KS 67218-2951
- **Mailing address phone:** (316) 681-3757
- **Mailing address fax:** (316) 652-0602

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | 6557 | KS | Yes |

## Other

- **Enumeration date:** 01/12/2012
- **Last updated:** 02/09/2012