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General NPI Number Information
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NPI Number | 1053529842
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Entity Type | Individual
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Provider Name | JOSEPH A. REVAK DMD
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Gender | Male
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Dates
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Enumeration Date | 05/18/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3421 SWEET AIR RD
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City | JACKSONVILLE
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State | MD
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Zip | 21131-1812
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Country | US
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Telephone | 410-628-7050
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Fax | 410-628-1826
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Provider Business Mailing Address
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Address Line | 3421 SWEET AIR RD
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City | JACKSONVILLE
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State | MD
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Zip | 21131-1812
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Country | US
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Telephone | 410-628-7050
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Fax | 410-628-1826
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 6200
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License Number State | MD
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