Healthcare Provider Details

I. General information

NPI: 1306384631
Provider Name (Legal Business Name): JAMES GRAVENER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 S MAIN ST
SLIPPERY ROCK PA
16057-1247
US

IV. Provider business mailing address

234 S MAIN ST
SLIPPERY ROCK PA
16057-1247
US

V. Phone/Fax

Practice location:
  • Phone: 267-939-1435
  • Fax:
Mailing address:
  • Phone: 267-939-1435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS041141
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License NumberDA031831
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: