Active NPI
Luke William Revelt, DMD
- General Practice Dentistry
- Alton, IL
National Provider Identifier
1669088381
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 019032795
- Practice address
- 2800 College Ave
Alton, IL 62002-4742 - Phone
- (618) 474-7000
- NPI assigned
- Sep 17, 2020
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 019032795 | IL | Primary |
Addresses
Primary practice location
2800 College Ave
Alton, IL 62002-4742
Mailing address
4 Azalea CT
Edwardsville, IL 62025-3999
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019032795 | IL | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1600300800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1600300800000",
"number": "1669088381",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4 AZALEA CT",
"city": "EDWARDSVILLE",
"state": "IL",
"postal_code": "620253999"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2800 COLLEGE AVE",
"city": "ALTON",
"state": "IL",
"postal_code": "620024742",
"telephone_number": "618-474-7000"
}
],
"practiceLocations": [],
"basic": {
"last_name": "REVELT",
"first_name": "LUKE",
"middle_name": "WILLIAM",
"name_prefix": "Dr.",
"credential": "DMD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2020-09-17",
"last_updated": "2020-09-17",
"certification_date": "2020-09-17",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Dentist, General Practice",
"state": "IL",
"license": "019032795",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Alton, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 17, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.