Provider Demographics
NPI:1124118914
Name:PROVINES, JOE ALLAN (DMD)
Entity type:Individual
Prefix:DR
First Name:JOE
Middle Name:ALLAN
Last Name:PROVINES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:877 W FREMONT AVE
Mailing Address - Street 2:STE I2
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-2319
Mailing Address - Country:US
Mailing Address - Phone:650-964-4867
Mailing Address - Fax:650-964-4864
Practice Address - Street 1:105 SOUTH DR
Practice Address - Street 2:SUITE 200
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4311
Practice Address - Country:US
Practice Address - Phone:650-964-4867
Practice Address - Fax:650-964-4864
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA204401223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics