MEDICARE: REVEILLE DENTAL

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	22438	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477848315
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVEILLE DENTAL

Provider Business Mailing Address
First Line	:	3722 REVEILLE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77087-4529
Country	:	US
Telephone Number	:	713-645-0200
Fax Number	:	713-645-0402

Provider Business Practice Location Address
First Line	:	3722 REVEILLE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77087-4529
Country	:	US
Telephone Number	:	713-645-0200
Fax Number	:	713-645-0402

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARY N PHAN
Credential	:
Telephone Number	:	713-645-0200

Provider Enumeration Date	:	06/17/2011
Last Update Date	:	06/17/2011

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Directions to “REVEILLE DENTAL ” Practice Location

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