Healthcare Provider Details

I. General information

NPI: 1609385368
Provider Name (Legal Business Name): BRADLEY DAVID REVENIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2017
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BRANCH HEALTH CLINIC FALLON 383 CHURCHILL AVE
FALLON NV
89406
US

IV. Provider business mailing address

NMRTU FALLON 383 CHURCHILL AVE
FALLON NV
89406
US

V. Phone/Fax

Practice location:
  • Phone: 775-426-3164
  • Fax:
Mailing address:
  • Phone: 775-426-3164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9872
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: