Provider Demographics
NPI:1588741466
Name:REVIS, JOHN KENNEDY (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:KENNEDY
Last Name:REVIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2123 BEACON HILL DR
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906
Mailing Address - Country:US
Mailing Address - Phone:517-887-7200
Mailing Address - Fax:
Practice Address - Street 1:6035 EXECUTIVE DR
Practice Address - Street 2:STE 200
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911
Practice Address - Country:US
Practice Address - Phone:517-887-7200
Practice Address - Fax:517-887-1549
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901016303122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist