Provider Demographics
NPI:1528610961
Name:REVIGLIO, KAELIE LYNN (DMD)
Entity type:Individual
Prefix:DR
First Name:KAELIE
Middle Name:LYNN
Last Name:REVIGLIO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 PARKRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-5720
Mailing Address - Country:US
Mailing Address - Phone:775-287-8590
Mailing Address - Fax:
Practice Address - Street 1:550 HAMMILL LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-2045
Practice Address - Country:US
Practice Address - Phone:775-287-8590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV72261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice