Basic Information
| Provider Information | |||||||||
| NPI: | 1780695130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REVUR | ||||||||
| FirstName: | SUJATHA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | GENERAL DENTISTRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 QUEEN ST | ||||||||
| Address2: | DENTAL | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016102473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088607700 | ||||||||
| FaxNumber: | 5088607990 | ||||||||
| Practice Location | |||||||||
| Address1: | 26 QUEEN ST | ||||||||
| Address2: | DENTAL | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016102473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088607700 | ||||||||
| FaxNumber: | 5088607990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 19824 | MA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 1300709 | 05 | MA | MEDICAID | 41770 | 01 | MA | HARVARD PILGRIM | OTHER | 19824 | 01 | MA | ALTUS DENTAL | OTHER | 19824 | 01 | MA | AMERITAS | OTHER | Y10141 | 01 | MA | BCBS DENTAL-GROUP | OTHER | 19824 | 01 | MA | BCBS DENTAL | OTHER | 19824 | 01 | MA | ANTHEM BCBS DENTAL | OTHER | 19824 | 01 | MA | ANTHEM BLUECARE | OTHER | 19824 | 01 | MA | GUARDIAN DENTAL | OTHER |