Provider Demographics
NPI:1629649009
Name:MARRIOTT, GRACEN MCGUCKIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GRACEN
Middle Name:MCGUCKIN
Last Name:MARRIOTT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:GRACEN
Other - Middle Name:MARIE
Other - Last Name:MCGUCKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:7838 HUEBNER RD APT 4107
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-6126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11200 MENCHACA RD STE 1
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-2747
Practice Address - Country:US
Practice Address - Phone:512-646-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX38839122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program