Provider Demographics
NPI:1356071617
Name:REVIVE DENTAL STUDIO LLC
Entity Type:Organization
Organization Name:REVIVE DENTAL STUDIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:AZADEH
Authorized Official - Middle Name:MAY
Authorized Official - Last Name:DIANAT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-578-4423
Mailing Address - Street 1:178 N 11TH ST APT 7D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-1134
Mailing Address - Country:US
Mailing Address - Phone:404-578-4423
Mailing Address - Fax:
Practice Address - Street 1:10 W HANOVER AVE STE 101
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-4221
Practice Address - Country:US
Practice Address - Phone:973-895-4333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty