Provider Demographics
NPI:1013070879
Name:RAVENEL, THEODORE D V (DMD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:D
Last Name:RAVENEL
Suffix:V
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:864-987-7030
Mailing Address - Fax:864-987-0198
Practice Address - Street 1:173 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-5908
Practice Address - Country:US
Practice Address - Phone:843-792-3661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37111223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics