Provider Demographics
NPI:1306384631
Name:GRAVENER, JAMES
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:GRAVENER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SLIPPERY ROCK
Mailing Address - State:PA
Mailing Address - Zip Code:16057-1247
Mailing Address - Country:US
Mailing Address - Phone:267-939-1435
Mailing Address - Fax:
Practice Address - Street 1:234 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SLIPPERY ROCK
Practice Address - State:PA
Practice Address - Zip Code:16057-1247
Practice Address - Country:US
Practice Address - Phone:267-939-1435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041141122300000X
PADA0318311223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDental Anesthesiology
No122300000XDental ProvidersDentist