Provider Demographics
NPI:1750669388
Name:ABERNATHEY, GRANT THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:THOMAS
Last Name:ABERNATHEY
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 1:4700 BUREAU RD S
Mailing Address - Street 2:FCC TERRE HAUTE ATTN: DENTAL
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802
Mailing Address - Country:US
Mailing Address - Phone:812-244-4595
Mailing Address - Fax:812-244-4791
Practice Address - Street 1:4700BUREAU RD S
Practice Address - Street 2:FCC TERRE HAUTE DENTAL UNIT
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802
Practice Address - Country:US
Practice Address - Phone:812-244-4595
Practice Address - Fax:812-244-4791
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA088651223G0001X
WI6828-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice