MEDICARE: WILLIAM REVIE, KENNETH BRITTON

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	122300000X	Dentist	56035	CA

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	:	1679766554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM REVIE, KENNETH BRITTON

Provider Business Mailing Address
First Line	:	6148 PASEO GRANITO
Second Line	:
City	:	CARLSBAD
State	:	CA
Zip	:	92009-2274
Country	:	US
Telephone Number	:	562-832-2489
Fax Number	:	858-566-6528

Provider Business Practice Location Address
First Line	:	9292 MIRA MESA BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-4806
Country	:	US
Telephone Number	:	858-566-4200
Fax Number	:	858-566-6528

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

Provider Enumeration Date	:	08/23/2007
Last Update Date	:	07/03/2014

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