Provider Demographics
NPI:1073642823
Name:BERIDZE, REVAZ (DDS)
Entity Type:Individual
Prefix:
First Name:REVAZ
Middle Name:
Last Name:BERIDZE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10440 QUEENS BLVD
Mailing Address - Street 2:#1Y
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3658
Mailing Address - Country:US
Mailing Address - Phone:718-459-3159
Mailing Address - Fax:718-459-3148
Practice Address - Street 1:10440 QUEENS BLVD
Practice Address - Street 2:#1Y
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3658
Practice Address - Country:US
Practice Address - Phone:718-459-3159
Practice Address - Fax:718-459-3148
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046224-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01616279Medicaid