Provider Demographics
NPI:1790479210
Name:REVERE DENTAL
Entity Type:Organization
Organization Name:REVERE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:GIRGIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:815-933-6100
Mailing Address - Street 1:588 WILLIAM LATHAM DR STE 2
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:588 WILLIAM LATHAM DR STE 2
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2340
Practice Address - Country:US
Practice Address - Phone:815-933-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental