Provider Demographics
NPI:1063551877
Name:PRIMAVERA, JOHN ARTHUR (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ARTHUR
Last Name:PRIMAVERA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1239 N COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-1934
Mailing Address - Country:US
Mailing Address - Phone:631-751-0099
Mailing Address - Fax:631-751-2557
Practice Address - Street 1:1239 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-1934
Practice Address - Country:US
Practice Address - Phone:631-751-0099
Practice Address - Fax:631-751-2557
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0273181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice