Provider Demographics
NPI:1326210998
Name:YELENA M REVICH DDS LTD
Entity Type:Organization
Organization Name:YELENA M REVICH DDS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YELENA
Authorized Official - Middle Name:M
Authorized Official - Last Name:REVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-494-5819
Mailing Address - Street 1:1455 E GOLF RD
Mailing Address - Street 2:# 209
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1250
Mailing Address - Country:US
Mailing Address - Phone:847-296-3733
Mailing Address - Fax:
Practice Address - Street 1:1455 E GOLF RD
Practice Address - Street 2:# 209
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1250
Practice Address - Country:US
Practice Address - Phone:847-296-3733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9177154Medicaid