=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891388633
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVALEX PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2021
-----------------------------------------------------
Last Update Date | 02/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28 WASHINGTON ST
-----------------------------------------------------
City | LEOMINSTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01453-3126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-405-1879
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 126 LYMAN RD
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01503-1804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-405-1879
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL DENTIST
-----------------------------------------------------
Name | DR. JACQUELINE ANDREA LUCERO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 781-405-1879
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------