Provider Demographics
NPI:1669117495
Name:REVELLO, KATHLEEN ANN (RDH)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:REVELLO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E VERONA AVE
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-8717
Mailing Address - Country:US
Mailing Address - Phone:608-845-6601
Mailing Address - Fax:608-845-1264
Practice Address - Street 1:1100 E VERONA AVE
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593-8717
Practice Address - Country:US
Practice Address - Phone:608-845-6601
Practice Address - Fax:608-845-1264
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4036-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist