Revana Emad Awadallah, DMD

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

D14808 Issued in MN

Practice address

29663 Gateway Ave
Chisago City, MN 55013-0339

Phone

(651) 257-3639

NPI assigned

Jul 13, 2022

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Modern Dental Professionals Minnesota PC

  • General Practice Dentistry
  • Chisago City, MN
  • NPI 1043589484

  General Practice

  NPD (past)

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

{
    "created_epoch": "1657670400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1657670400000",
    "number": "1972237089",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7741 WINTER WHEAT WAY",
            "city": "WOODBURY",
            "state": "MN",
            "postal_code": "551292401",
            "telephone_number": "651-274-7561"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "29663 GATEWAY AVE",
            "city": "CHISAGO CITY",
            "state": "MN",
            "postal_code": "550130339",
            "telephone_number": "651-257-3639"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "AWADALLAH",
        "first_name": "REVANA",
        "middle_name": "EMAD",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2022-07-13",
        "last_updated": "2022-07-13",
        "certification_date": "2022-05-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MN",
            "license": "D14808",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Acres for Life Therapy & Wellness Center
• David Bruce Albrecht, D.D.S.
• Nancy L Alexis, MD
• Dana Marie Andersen
• Amy Christopherson Anderson, MD
• Jessica Ria Babcock, PA-C
• Courtney Marie Bagley, M.A. LMFT
• Natasha Barnes, LMFT
• Riley Scott Baumgartner, DDS
• Danielle Kallin Brink, DC

• All providers in Chisago City, MN
• General Practice Dentistry in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 13, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.