Provider Demographics
NPI:1164241600
Name:PROVANCHA, LAURA MARIE (RDH)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:PROVANCHA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2741 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-4737
Mailing Address - Country:US
Mailing Address - Phone:843-592-7987
Mailing Address - Fax:
Practice Address - Street 1:188 SUMMER ST
Practice Address - Street 2:
Practice Address - City:DOVER FOXCROFT
Practice Address - State:ME
Practice Address - Zip Code:04426-1129
Practice Address - Country:US
Practice Address - Phone:207-538-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10586124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist