Provider Demographics
NPI:1538319348
Name:LAVENE, REBECCA ANN (DMD)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ANN
Last Name:LAVENE
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 1:2152 MCCULLOCH BLVD N STE C
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6805
Mailing Address - Country:US
Mailing Address - Phone:928-854-5551
Mailing Address - Fax:928-733-6128
Practice Address - Street 1:2152 MCCULLOCH BLVD N STE C
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6805
Practice Address - Country:US
Practice Address - Phone:310-947-2631
Practice Address - Fax:310-947-2631
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ88231223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics