Provider Demographics
NPI:1437421310
Name:REVEL DENTAL,PSC
Entity Type:Organization
Organization Name:REVEL DENTAL,PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:A
Authorized Official - Last Name:REVEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-887-3835
Mailing Address - Street 1:210 BELLAIRE DR
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-8840
Mailing Address - Country:US
Mailing Address - Phone:895-887-3835
Mailing Address - Fax:859-887-0351
Practice Address - Street 1:210 BELLAIRE DR
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-8840
Practice Address - Country:US
Practice Address - Phone:859-887-3835
Practice Address - Fax:859-887-0351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY71281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100186980Medicaid