MEDICARE: DR. JOSEPH A. REVAK DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	6200	MD

General Provider Information

NPI Number	:	1053529842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSEPH A. REVAK DMD

Provider Business Mailing Address
First Line	:	3421 SWEET AIR RD
Second Line	:
City	:	JACKSONVILLE
State	:	MD
Zip	:	21131-1812
Country	:	US
Telephone Number	:	410-628-7050
Fax Number	:	410-628-1826

Provider Business Practice Location Address
First Line	:	3421 SWEET AIR RD
Second Line	:
City	:	JACKSONVILLE
State	:	MD
Zip	:	21131-1812
Country	:	US
Telephone Number	:	410-628-7050
Fax Number	:	410-628-1826

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2007
Last Update Date	:	07/08/2007

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