Provider Demographics
NPI:1609385368
Name:REVENIS, BRADLEY DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DAVID
Last Name:REVENIS
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 1:21ST DENTAL COMPANY, 3RD DENTAL BN
Mailing Address - Street 2:BLDG 6905, HARRIS AV
Mailing Address - City:KANEOHE BAY
Mailing Address - State:HI
Mailing Address - Zip Code:96863
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HEALTH CLINIC HAWAII
Practice Address - Street 2:480 CENTRAL AVENUE
Practice Address - City:PEARL HARBOR
Practice Address - State:HI
Practice Address - Zip Code:96860
Practice Address - Country:US
Practice Address - Phone:808-257-3365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9872122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist