Provider Demographics
NPI:1619958600
Name:GRADOVILLE, BERNARD L (DDS)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:L
Last Name:GRADOVILLE
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 1:2800 INGERSOLL AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-4013
Mailing Address - Country:US
Mailing Address - Phone:515-243-2412
Mailing Address - Fax:515-243-1248
Practice Address - Street 1:2800 INGERSOLL AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-4013
Practice Address - Country:US
Practice Address - Phone:515-243-2412
Practice Address - Fax:515-243-1248
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA72501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0048066Medicaid