Provider Demographics
NPI:1437899812
Name:REVITAL DENTAL PLLC
Entity Type:Organization
Organization Name:REVITAL DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SUMAN
Authorized Official - Middle Name:KISHORE
Authorized Official - Last Name:KONDRAGUNTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:347-631-0848
Mailing Address - Street 1:4311 S 31ST ST STE 145
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-3346
Mailing Address - Country:US
Mailing Address - Phone:347-631-0848
Mailing Address - Fax:
Practice Address - Street 1:4311 S 31ST ST STE 145
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-3346
Practice Address - Country:US
Practice Address - Phone:347-631-0848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-01
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty