Provider Demographics
NPI:1225251036
Name:GRAVELINE, ARTHUR JOSEPH IV
Entity Type:Individual
Prefix:DR
First Name:ARTHUR
Middle Name:JOSEPH
Last Name:GRAVELINE
Suffix:IV
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:ARTHUR
Other - Middle Name:JOSEPH
Other - Last Name:GRAVELINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:899 MARION AVE
Mailing Address - Street 2:PO BOX 305
Mailing Address - City:MARION
Mailing Address - State:CT
Mailing Address - Zip Code:06444
Mailing Address - Country:US
Mailing Address - Phone:860-621-4396
Mailing Address - Fax:
Practice Address - Street 1:899 MARION AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:CT
Practice Address - Zip Code:06444
Practice Address - Country:US
Practice Address - Phone:860-621-4396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT40951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice