Provider Demographics
NPI:1376934802
Name:REVAWALA, AMISHA
Entity Type:Individual
Prefix:
First Name:AMISHA
Middle Name:
Last Name:REVAWALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5721 TIMBERGATE DR APT 11201
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-2171
Mailing Address - Country:US
Mailing Address - Phone:786-499-2374
Mailing Address - Fax:
Practice Address - Street 1:5721 TIMBERGATE DR APT 11201
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-2171
Practice Address - Country:US
Practice Address - Phone:786-499-2374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN00202436122300000X
TX31957122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist