MEDICARE: DR. RICHARD T. PROVINE D.M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	1821	SC

General Provider Information

NPI Number	:	1811074735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD T. PROVINE D.M.D

Provider Business Mailing Address
First Line	:	108 AMBER DR
Second Line	:
City	:	INMAN
State	:	SC
Zip	:	29349-9568
Country	:	US
Telephone Number	:	864-472-5708
Fax Number	:

Provider Business Practice Location Address
First Line	:	1111 W O EZELL BLVD
Second Line	:	STE.A
City	:	SPARTANBURG
State	:	SC
Zip	:	29301-1655
Country	:	US
Telephone Number	:	864-576-0943
Fax Number	:	864-576-7989

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	05/07/2008

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