Healthcare Provider Details

I. General information

NPI: 1124644612
Provider Name (Legal Business Name): REVAN DAWOOD DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4365 E PECOS RD STE 127
GILBERT AZ
85295-8052
US

IV. Provider business mailing address

4365 E PECOS RD STE 127
GILBERT AZ
85295-8052
US

V. Phone/Fax

Practice location:
  • Phone: 480-331-4955
  • Fax:
Mailing address:
  • Phone: 480-331-4955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD010736
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: