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General NPI Number Information
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NPI Number | 1669060364
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Entity Type | Organization
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Legal Business Name | JESSICA RUSSO REVAND, DMD, MS, PLLC
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Dates
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Enumeration Date | 01/07/2021
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Last Update Date | 01/07/2021
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Provider Practice Location Address
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Address Line | 8987 HERSAND DR STE 3
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City | BURKE
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State | VA
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Zip | 22015-1604
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Country | US
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Telephone | 703-503-0555
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Fax |
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Provider Business Mailing Address
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Address Line | 10603 OLIVER ST
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City | FAIRFAX
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State | VA
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Zip | 22030-3913
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Country | US
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Telephone | 202-270-4779
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Fax |
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Authorized Official
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Title or Position | OWNER/ENDODONTIST
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Name | DR. JESSICA RUSSO REVAND
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Credential | DMD, MS
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Telephone | 703-503-0555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number |
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License Number State |
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