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General NPI Number Information
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NPI Number | 1710109145
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Entity Type | Organization
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Legal Business Name | D J PROVENZALE & D J PROVENZALE JR
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4336 SARATOGA AVE
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City | DOWNERS GROVE
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State | IL
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Zip | 60515
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Country | US
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Telephone | 630-969-7711
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Fax | 630-969-7723
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Provider Business Mailing Address
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Address Line | 4336 SARATOGA AVE
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City | DOWNERS GROVE
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State | IL
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Zip | 60515
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Country | US
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Telephone | 630-969-7711
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Fax | 630-969-7723
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Authorized Official
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Title or Position | PARTNER
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Name | DR. DONALD J PROVENZALE JR.
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Credential | DDS
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Telephone | 630-969-7711
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 19A12314
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 19021170
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License Number State | IL
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