Provider Demographics
NPI:1770712705
Name:RUSSO REVAND, JESSICA (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:RUSSO REVAND
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 KENMORE AVE
Mailing Address - Street 2:SUITE 700
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1313
Mailing Address - Country:US
Mailing Address - Phone:703-370-1327
Mailing Address - Fax:703-370-1907
Practice Address - Street 1:4660 KENMORE AVE
Practice Address - Street 2:SUITE 700
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1313
Practice Address - Country:US
Practice Address - Phone:703-370-1327
Practice Address - Fax:703-370-1907
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014125091223E0200X
DCDEN10008271223E0200X
CA515171223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics