MEDICARE: PHILLIP JOSEPH GRAVINO DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	11447	MO

General Provider Information

NPI Number	:	1477762151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP JOSEPH GRAVINO DDS

Provider Business Mailing Address
First Line	:	400 E RED BRIDGE ROAD
Second Line	:	SUITE 216
City	:	KANSAS CITY
State	:	MO
Zip	:	64131-4030
Country	:	US
Telephone Number	:	816-942-4330
Fax Number	:	816-942-4331

Provider Business Practice Location Address
First Line	:	400 E RED BRIDGE ROAD
Second Line	:	SUITE 216
City	:	KANSAS CITY
State	:	MO
Zip	:	64131-4030
Country	:	US
Telephone Number	:	816-942-4330
Fax Number	:	816-942-4331

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/08/2007

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