Provider Demographics
NPI:1639195563
Name:GRAVEL, ROGER EDMUND (DDS)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:EDMUND
Last Name:GRAVEL
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 1:1601 YARMOUTH LN
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8001
Mailing Address - Country:US
Mailing Address - Phone:336-945-9004
Mailing Address - Fax:336-718-1835
Practice Address - Street 1:201 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1507
Practice Address - Country:US
Practice Address - Phone:336-718-1869
Practice Address - Fax:336-718-1835
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC44361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4436OtherDENTAL LICENCE