Provider Demographics
NPI:1932671708
Name:REVOLUTION DENTAL
Entity Type:Organization
Organization Name:REVOLUTION DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:ALEXANDER-MUTTER
Authorized Official - Last Name:LEONARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-498-6160
Mailing Address - Street 1:456 IDA PL
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:IL
Mailing Address - Zip Code:60022-1913
Mailing Address - Country:US
Mailing Address - Phone:312-498-6160
Mailing Address - Fax:
Practice Address - Street 1:113 E SCHAUMBURG RD
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60194-3518
Practice Address - Country:US
Practice Address - Phone:847-301-1818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental