Provider Demographics
NPI:1477762151
Name:GRAVINO, PHILLIP JOSEPH (DDS)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:JOSEPH
Last Name:GRAVINO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E RED BRIDGE ROAD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-4030
Mailing Address - Country:US
Mailing Address - Phone:816-942-4330
Mailing Address - Fax:816-942-4331
Practice Address - Street 1:400 E RED BRIDGE ROAD
Practice Address - Street 2:SUITE 216
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64131-4030
Practice Address - Country:US
Practice Address - Phone:816-942-4330
Practice Address - Fax:816-942-4331
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice