Healthcare Provider Details

I. General information

NPI: 1700951795
Provider Name (Legal Business Name): RAJEEV N REVANKAR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 02/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8403 ROCHESTER RD
GASPORT NY
14067-9211
US

IV. Provider business mailing address

8403 ROCHESTER RD APT 1GB
GASPORT NY
14067-9211
US

V. Phone/Fax

Practice location:
  • Phone: 716-772-5590
  • Fax:
Mailing address:
  • Phone: 716-772-5590
  • Fax: 716-772-5590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number052240
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: