Provider Demographics
NPI:1023158797
Name:REVARD, PAUL D
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:D
Last Name:REVARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 WASHINGTON AVE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708
Mailing Address - Country:US
Mailing Address - Phone:989-893-2140
Mailing Address - Fax:989-893-0423
Practice Address - Street 1:916 WASHINGTON AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708
Practice Address - Country:US
Practice Address - Phone:989-893-2140
Practice Address - Fax:989-893-0423
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI12915122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist