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General NPI Number Information
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NPI Number | 1811074735
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Entity Type | Individual
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Provider Name | RICHARD T. PROVINE D.M.D
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Gender | Male
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 05/07/2008
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Provider Practice Location Address
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Address Line | 1111 W O EZELL BLVD STE.A
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City | SPARTANBURG
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State | SC
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Zip | 29301-1655
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Country | US
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Telephone | 864-576-0943
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Fax | 864-576-7989
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Provider Business Mailing Address
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Address Line | 108 AMBER DR
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City | INMAN
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State | SC
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Zip | 29349-9568
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Country | US
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Telephone | 864-472-5708
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 1821
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License Number State | SC
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