Provider Demographics
NPI:1891251831
Name:REVOLUTIONARY BRIER HILL LLC
Entity Type:Organization
Organization Name:REVOLUTIONARY BRIER HILL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-239-0565
Mailing Address - Street 1:1151 BROAD ST STE 216
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:07702-4328
Mailing Address - Country:US
Mailing Address - Phone:732-239-0565
Mailing Address - Fax:
Practice Address - Street 1:E7 BRIER HILL CT
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-3336
Practice Address - Country:US
Practice Address - Phone:732-239-0565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REVOLUTIONARY DENTAL MANAGEMENT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty