Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 3711 | SC |
NPI | 1013070879 |
---|---|
Provider Name | Dr. Theodore D Ravenel V |
First Address | Greenville, SC 29607-5908 |
Second Address | Charleston, SC 29425-5908 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/12/2006 |
Last Update Date | 17/03/2018 |