Provider Demographics
NPI:1710416532
Name:THROCKMORTON, GRANT (DDS)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:
Last Name:THROCKMORTON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 LORETTO DR
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2076
Mailing Address - Country:US
Mailing Address - Phone:276-228-2222
Mailing Address - Fax:
Practice Address - Street 1:210 LORETTO DR
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2076
Practice Address - Country:US
Practice Address - Phone:276-228-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401415663122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist