Provider Demographics
NPI:1821420464
Name:MICHAEL J.REVENIG DDS, GLENN D. WILSON DDS, PLLC
Entity Type:Organization
Organization Name:MICHAEL J.REVENIG DDS, GLENN D. WILSON DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER'S WIFE
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:U
Authorized Official - Last Name:REVENIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-698-6005
Mailing Address - Street 1:4601 BRAINERD RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-3826
Mailing Address - Country:US
Mailing Address - Phone:423-698-6005
Mailing Address - Fax:423-698-6410
Practice Address - Street 1:4601 BRAINERD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-3826
Practice Address - Country:US
Practice Address - Phone:423-698-6005
Practice Address - Fax:423-698-6410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty