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 1:1430 JOHN WESLEY GILBERT DRIVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0001
Mailing Address - Country:US
Mailing Address - Phone:706-721-2371
Mailing Address - Fax:
Practice Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0001
Practice Address - Country:US
Practice Address - Phone:706-721-2371
Practice Address - Fax:706-721-6778
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37111223E0200X
GADNF0004631223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics