Provider Demographics
NPI:1972237089
Name:AWADALLAH, REVANA EMAD (DMD)
Entity Type:Individual
Prefix:DR
First Name:REVANA
Middle Name:EMAD
Last Name:AWADALLAH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7741 WINTER WHEAT WAY
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-2401
Mailing Address - Country:US
Mailing Address - Phone:651-274-7561
Mailing Address - Fax:
Practice Address - Street 1:29663 GATEWAY AVE
Practice Address - Street 2:
Practice Address - City:CHISAGO CITY
Practice Address - State:MN
Practice Address - Zip Code:55013-0339
Practice Address - Country:US
Practice Address - Phone:651-257-3639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND148081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice