Provider Demographics
NPI:1124208285
Name:REVELS, MARK JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JAMES
Last Name:REVELS
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 1:2214 W BOYD ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-4836
Mailing Address - Country:US
Mailing Address - Phone:405-321-2735
Mailing Address - Fax:405-321-7877
Practice Address - Street 1:2214 W BOYD ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-4836
Practice Address - Country:US
Practice Address - Phone:405-321-2735
Practice Address - Fax:405-321-7877
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1661223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics