Provider Demographics
NPI:1932834454
Name:REVIVE DENTAL SLEEP SOLUTIONS, LLC
Entity Type:Organization
Organization Name:REVIVE DENTAL SLEEP SOLUTIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DE60579213
Authorized Official - Phone:425-353-5854
Mailing Address - Street 1:2121 MADISON ST STE A
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-5375
Mailing Address - Country:US
Mailing Address - Phone:425-353-5854
Mailing Address - Fax:425-355-7426
Practice Address - Street 1:2121 MADISON ST STE A
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-5375
Practice Address - Country:US
Practice Address - Phone:425-353-5854
Practice Address - Fax:425-355-7426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-19
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies