Provider Demographics
NPI:1669060364
Name:JESSICA RUSSO REVAND, DMD, MS, PLLC
Entity type:Organization
Organization Name:JESSICA RUSSO REVAND, DMD, MS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ENDODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO REVAND
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:703-503-0555
Mailing Address - Street 1:10603 OLIVER ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-3913
Mailing Address - Country:US
Mailing Address - Phone:202-270-4779
Mailing Address - Fax:
Practice Address - Street 1:8987 HERSAND DR STE 3
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-1604
Practice Address - Country:US
Practice Address - Phone:703-503-0555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty