Healthcare Provider Details

I. General information

NPI: 1790065019
Provider Name (Legal Business Name): REVENDA BEBAWI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 28038 USA DENTAC BAVARIA
APO AE
09112
US

IV. Provider business mailing address

UNIT 28038 USA DENTAC BAVARIA
APO AE
09112
US

V. Phone/Fax

Practice location:
  • Phone: 01149637194643980
  • Fax:
Mailing address:
  • Phone: 01149637194643980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401414056
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: