MEDICARE: REVALEX PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1891388633
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVALEX PLLC

Provider Business Mailing Address
First Line	:	126 LYMAN RD
Second Line	:
City	:	BERLIN
State	:	MA
Zip	:	01503-1804
Country	:	US
Telephone Number	:	781-405-1879
Fax Number	:

Provider Business Practice Location Address
First Line	:	28 WASHINGTON ST
Second Line	:
City	:	LEOMINSTER
State	:	MA
Zip	:	01453-3126
Country	:	US
Telephone Number	:	781-405-1879
Fax Number	:

Authorized Official
Title or Position	:	GENERAL DENTIST
Name	:	DR. JACQUELINE ANDREA LUCERO
Credential	:	DDS
Telephone Number	:	781-405-1879

Provider Enumeration Date	:	02/12/2021
Last Update Date	:	02/12/2021

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