MEDICARE: DR. NICOLAS ANDREAS RAVON DDS, MSD

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	1223P0300X	Periodontics	44533	CA

General Provider Information

NPI Number	:	1942492178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLAS ANDREAS RAVON DDS, MSD

Provider Business Mailing Address
First Line	:	3808 W RIVERSIDE DR STE 305
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-4339
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3808 W RIVERSIDE DR STE 305
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-4339
Country	:	US
Telephone Number	:	818-558-7454
Fax Number	:

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

Provider Enumeration Date	:	08/12/2007
Last Update Date	:	08/12/2007

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