Provider Demographics
NPI:1891703419
Name:RAVENEL, LISA S (DMD, MHS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:S
Last Name:RAVENEL
Suffix:
Gender:F
Credentials:DMD, MHS
Other - Prefix:DR
Other - First Name:BRYAN
Other - Middle Name:E
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD, MDS
Mailing Address - Street 1:1130 E BUTLER RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5908
Mailing Address - Country:US
Mailing Address - Phone:864-987-9700
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:864-987-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37101223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics