Provider Demographics
NPI:1659634475
Name:GRAVELLE, JOSHUA THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:THOMAS
Last Name:GRAVELLE
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:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38503-0357
Mailing Address - Country:US
Mailing Address - Phone:931-528-5105
Mailing Address - Fax:931-528-5118
Practice Address - Street 1:327 N CEDAR AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2420
Practice Address - Country:US
Practice Address - Phone:931-528-5105
Practice Address - Fax:931-528-5118
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9490122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1531415Medicaid