Provider Demographics
NPI:1376614651
Name:REVILLA, MARIA GEORGIA ESCALANTE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARIA GEORGIA
Middle Name:ESCALANTE
Last Name:REVILLA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1539 PRINCE JOHN CIRCLE
Mailing Address - Street 2:
Mailing Address - City:OAKVILLE
Mailing Address - State:ON
Mailing Address - Zip Code:L6J6T4
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:344 E 6TH ST
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638-3631
Practice Address - Country:US
Practice Address - Phone:559-664-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53856122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist