MEDICARE: DR. WILLIAM P REVILLE 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
1	1223G0001X	General Practice Dentistry	OK4426	OK

General Provider Information

NPI Number	:	1871504191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM P REVILLE D.D.S.

Provider Business Mailing Address
First Line	:	3804 N MACARTHUR BLVD
Second Line	:
City	:	WARR ACRES
State	:	OK
Zip	:	73122-2016
Country	:	US
Telephone Number	:	405-789-5552
Fax Number	:	405-789-8201

Provider Business Practice Location Address
First Line	:	3804 N MACARTHUR BLVD
Second Line	:
City	:	WARR ACRES
State	:	OK
Zip	:	73122-2016
Country	:	US
Telephone Number	:	405-789-5552
Fax Number	:	405-789-8201

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

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	07/08/2007

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