The holder whose full name is Provence, Timothy D.,come from INDIANAPOLIS IN,hold the CSR-Dentist license(NO.12008606B) which status is Expired.
| Name | Provence, Timothy D. |
|---|---|
| License Number | 12008606B |
| License Type | CSR-Dentist |
| License Status | Expired |
| City | INDIANAPOLIS |
| State | IN |