| NPI | 1639449259 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JOHN R PROVENZANO Owner 316-681-3757 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: KS 6557) |
| Enumeration Date | 2012-01-12 |
| Last Update Date | 2012-02-09 |