Basic Information
| Provider Information | |||||||||
| NPI: | 1003309279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REVIS | ||||||||
| FirstName: | GABIJA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 755 WORTHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011051140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137319575 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4201 RUCKER AVE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982032215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253824000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2018 | ||||||||
| LastUpdateDate: | 08/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DN1858579 | MA | N | Dental Providers | Dentist | 1223G0001X | 00203586 | CO | N | Dental Providers | Dentist | General Practice | 1223G0001X | DE61301658 | WA | Y | Dental Providers | Dentist | General Practice |
No ID Information.