Individual
CARL ROSS PROVENZANO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
625 19TH ST S, BIRMINGHAM, AL 35233-1900
(205) 934-4507
Mailing address
625 19TH ST S, BIRMINGHAM, AL 35233-1900
(205) 934-4507
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
12799
TN
1223G0001X
General Practice Dentistry
41386
TX
1223G0001X
General Practice Dentistry
Primary
D-6826-C1
AL
1223G0001X
General Practice Dentistry
D12166
OR
1223G0001X
General Practice Dentistry
DS045261
PA
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
D-6826-C1
AL
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
03/10/2020
Last updated
08/25/2025
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