Healthcare Provider Details

I. General information

NPI: 1457693020
Provider Name (Legal Business Name): JOSE GREGORIO RAVELO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2013
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 VIRGINIA ST E
CHARLESTON WV
25301-2908
US

IV. Provider business mailing address

103 STATION PLACE WAY
HURRICANE WV
25526-8747
US

V. Phone/Fax

Practice location:
  • Phone: 304-345-1092
  • Fax:
Mailing address:
  • Phone: 304-720-7819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4371
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: