Provider Demographics
NPI:1487874400
Name:PROVO, JOSEPH W III (DDS)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:W
Last Name:PROVO
Suffix:III
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 1:1460 IH 10 EAST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77703
Mailing Address - Country:US
Mailing Address - Phone:409-833-0261
Mailing Address - Fax:409-833-0543
Practice Address - Street 1:1460 IH 10 EAST
Practice Address - Street 2:SUITE A
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77703
Practice Address - Country:US
Practice Address - Phone:409-833-0261
Practice Address - Fax:409-833-0543
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16452122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist