Provider Demographics
NPI:1811074735
Name:PROVINE, RICHARD T (DMD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:T
Last Name:PROVINE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 AMBER DR
Mailing Address - Street 2:
Mailing Address - City:INMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29349-9568
Mailing Address - Country:US
Mailing Address - Phone:864-472-5708
Mailing Address - Fax:
Practice Address - Street 1:1111 W O EZELL BLVD
Practice Address - Street 2:STE.A
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-1655
Practice Address - Country:US
Practice Address - Phone:864-576-0943
Practice Address - Fax:864-576-7989
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice