MEDICARE: REVIVE DENTAL, PA

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	27280	TX

General Provider Information

NPI Number	:	1184024887
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE DENTAL, PA

Provider Business Mailing Address
First Line	:	2728 MCKINNON ST
Second Line	:	APT 1517
City	:	DALLAS
State	:	TX
Zip	:	75201-1602
Country	:	US
Telephone Number	:	415-971-4727
Fax Number	:

Provider Business Practice Location Address
First Line	:	3879 IRVING MALL
Second Line	:	K-2A
City	:	IRVING
State	:	TX
Zip	:	75062-5159
Country	:	US
Telephone Number	:	214-574-4867
Fax Number	:	469-417-0802

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. YONG HO CHO
Credential	:	DDS
Telephone Number	:	415-971-4727

Provider Enumeration Date	:	08/29/2014
Last Update Date	:	08/29/2014

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