Provider Demographics
NPI:1720827934
Name:REVELIS, ELEANOR MARIA (DDS)
Entity type:Individual
Prefix:
First Name:ELEANOR
Middle Name:MARIA
Last Name:REVELIS
Suffix:
Gender:
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:N9023 LAKESHORE RD
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-5123
Mailing Address - Country:US
Mailing Address - Phone:920-918-5399
Mailing Address - Fax:
Practice Address - Street 1:7631 CASS ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3623
Practice Address - Country:US
Practice Address - Phone:402-393-0594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00206047122300000X
390200000X
NE8068122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program