Provider Demographics
NPI:1639169956
Name:REVICH, YELENA M (DDS)
Entity type:Individual
Prefix:DR
First Name:YELENA
Middle Name:M
Last Name:REVICH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5005 WARREN ST
Mailing Address - Street 2:# 409
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-2986
Mailing Address - Country:US
Mailing Address - Phone:847-568-5819
Mailing Address - Fax:
Practice Address - Street 1:3205 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3301
Practice Address - Country:US
Practice Address - Phone:332-267-2671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026450122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9177154Medicaid