Revival Dermatology PLLC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

Legal business name

REVIVAL DERMATOLOGY PLLC

Practice address

8201 Preston Rd Ste 440
Dallas, TX 75225-6209

Phone

(214) 675-3227

Fax

(972) 435-4481

NPI assigned

May 30, 2021

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Lisa Guidry Pruett, MD

Title

President

Phone

(504) 319-1407

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in TX

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Interoperability endpoints

• FHIR API: https://app.meldrx.com/api/fhir/ez_00246

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Amanda Hope Champlain, M.D.

  • Dermatology Physician
  • Frisco, TX
  • NPI 1003180993
  Medicare reassignment Care Compare group NPD
• Lisa Ann Guidry Pruett, MD

  • Dermatology Physician
  • Dallas, TX
  • NPI 1356367106
  Medicare reassignment Care Compare group NPD
• Jon Davis Pruett, M.D.

  • Dermatology Physician
  • Dallas, TX
  • NPI 1023071933
  Medicare reassignment Care Compare group NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1622332800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1623369600000",
    "number": "1679149702",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8201 PRESTON RD STE 440",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752256209",
            "telephone_number": "214-675-3227"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8201 PRESTON RD STE 440",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752256209",
            "telephone_number": "214-675-3227",
            "fax_number": "972-435-4481"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVIVAL DERMATOLOGY PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-05-30",
        "last_updated": "2021-06-11",
        "certification_date": "2021-06-11",
        "status": "A",
        "authorized_official_last_name": "PRUETT",
        "authorized_official_first_name": "LISA",
        "authorized_official_middle_name": "GUIDRY",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "504-319-1407",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Camille Haworth Rever
• Robert Rever, PT, DPT
• Marta Revilla-Leon, DDS, MSD
• Leslie Revilla
• Revision Counseling Services
• Revival Homecare of Dallas, Inc.
• Revive Health
• Revive PCMS Highland Park PLLC
• Revive Therapeutic Center
• Revive to Thrive Wellness Center, PLLC

• Dermatology Physician in Dallas, TX
• Providers in Dallas, TX by specialty
• Dermatology Physician in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 11, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.