Provider Demographics
NPI:1013569771
Name:RAVENEL PERIODONTICS, PA
Entity Type:Organization
Organization Name:RAVENEL PERIODONTICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:SHERWOOD
Authorized Official - Last Name:RAVENEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:864-626-4777
Mailing Address - Street 1:PO BOX 938
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-0938
Mailing Address - Country:US
Mailing Address - Phone:864-626-4777
Mailing Address - Fax:
Practice Address - Street 1:1130 E BUTLER RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5908
Practice Address - Country:US
Practice Address - Phone:864-626-4777
Practice Address - Fax:864-626-4779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty