Provider Demographics
NPI:1891388633
Name:REVALEX PLLC
Entity Type:Organization
Organization Name:REVALEX PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:ANDREA
Authorized Official - Last Name:LUCERO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:781-405-1879
Mailing Address - Street 1:126 LYMAN RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MA
Mailing Address - Zip Code:01503-1804
Mailing Address - Country:US
Mailing Address - Phone:781-405-1879
Mailing Address - Fax:
Practice Address - Street 1:28 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-3126
Practice Address - Country:US
Practice Address - Phone:781-405-1879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty