Provider Demographics
NPI:1154849198
Name:REVERE DENTISTRY AND BRACES LLC
Entity Type:Organization
Organization Name:REVERE DENTISTRY AND BRACES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICIER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-580-1524
Mailing Address - Street 1:5 MOUNT ROYAL AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-1900
Mailing Address - Country:US
Mailing Address - Phone:508-460-0632
Mailing Address - Fax:
Practice Address - Street 1:370 BROADWAY
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-5016
Practice Address - Country:US
Practice Address - Phone:781-629-6636
Practice Address - Fax:781-629-6034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-30
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110078301AMedicaid