Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DN1858579 | MA |
N | 1223G0001X | General Practice | 00203586 | CO |
N | 213EG0000X | General Practice | 00203586 | CO |
NPI | 1003309279 |
---|---|
Provider Name | Dr. Gabija Revis |
First Address | Springfield, MA 01105-1140 |
Second Address | Springfield, MA 01105-1140 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/06/2018 |
Last Update Date | 23/08/2021 |