Provider Demographics
NPI:1619661691
Name:REBOLLEDO, JAVIER EDUARDO (DMD)
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:EDUARDO
Last Name:REBOLLEDO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 BOWMAN WAY UNIT 308
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-1583
Mailing Address - Country:US
Mailing Address - Phone:239-834-9006
Mailing Address - Fax:
Practice Address - Street 1:1730 SCHROCK RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-1575
Practice Address - Country:US
Practice Address - Phone:614-890-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.027209122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist