Individual
ALEX PROVO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
200 E MAIN ST, ADA, MN 56510-1354
(218) 784-7119
Mailing address
18185 PARK DR, DETROIT LAKES, MN 56501-7977
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
D13521
MN
Other
Enumeration date
06/17/2015
Last updated
06/17/2015
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