Provider Demographics
NPI:1073101820
Name:GRANDIN FAMILY DENTISTRY
Entity Type:Organization
Organization Name:GRANDIN FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:BLAINE
Authorized Official - Last Name:GALLAHER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:540-344-9361
Mailing Address - Street 1:1602 GRANDIN RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-2308
Mailing Address - Country:US
Mailing Address - Phone:540-344-9361
Mailing Address - Fax:
Practice Address - Street 1:1602 GRANDIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-2308
Practice Address - Country:US
Practice Address - Phone:540-344-9361
Practice Address - Fax:540-344-9377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty