=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134242373
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEE A REVERENDO D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 LAFAYETTE ST
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07105-2725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-589-2904
-----------------------------------------------------
Fax | 973-589-1262
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 LAFAYETTE ST
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07105-2725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-589-2904
-----------------------------------------------------
Fax | 973-589-1262
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DI018176
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------