Provider Demographics
NPI:1700951795
Name:REVANKAR, RAJEEV N (DDS)
Entity Type:Individual
Prefix:
First Name:RAJEEV
Middle Name:N
Last Name:REVANKAR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8403 ROCHESTER RD
Mailing Address - Street 2:APT 1GB
Mailing Address - City:GASPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14067-9211
Mailing Address - Country:US
Mailing Address - Phone:716-772-5590
Mailing Address - Fax:716-772-5590
Practice Address - Street 1:8403 ROCHESTER RD
Practice Address - Street 2:
Practice Address - City:GASPORT
Practice Address - State:NY
Practice Address - Zip Code:14067-9211
Practice Address - Country:US
Practice Address - Phone:716-772-5590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052240122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00000000OtherDR DOESN'T HAVE