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NPI Code Detail

MEDICARE: DR. YELENA M REVICH D.D.S.

MEDICARE: DR. YELENA M REVICH D.D.S.
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
1122300000XDentist019026450IL

Other Identifiers

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

General Provider Information

NPI Number : 1639169956
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. YELENA M REVICH D.D.S.
Provider Business Mailing Address
First Line : 5005 WARREN ST
Second Line : # 409
City : SKOKIE
State : IL
Zip : 60077-2986
Country : US
Telephone Number : 847-568-5819
Fax Number :
Provider Business Practice Location Address
First Line : 3205 W IRVING PARK RD
Second Line :
City : CHICAGO
State : IL
Zip : 60618-3301
Country : US
Telephone Number : 332-267-2671
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/27/2005
Last Update Date : 12/12/2012

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